Article Text

Download PDFPDF

Original research
Polish adaptation and validation of the Perceived Implicit Rationing of Nursing Care (PIRNCA) questionnaire: a cross-sectional validation study
  1. Izabella Uchmanowicz1,
  2. Aleksandra Kołtuniuk2,
  3. Agnieszka Młynarska3,
  4. Katarzyna Łagoda4,
  5. Izabela Witczak5,
  6. Joanna Rosińczuk2,
  7. Terry Jones6
  1. 1Department of Clinical Nursing, Wroclaw Medical University, Wroclaw, Poland
  2. 2Department of Nervous System Diseases, Wroclaw Medical University, Wroclaw, Poland
  3. 3Department of Gerontology and Geriatric Nursing, Medical University of Silesia, Katowice, Poland
  4. 4Department of Clinical Medicine, Medical University of Bialystok, Bialystok, Poland
  5. 5Department of Economics and Quality in Health Care, Wroclaw Medical University, Wroclaw, Poland
  6. 6Department of Adult Health and Nursing Systems, Virginia Commonwealth University School of Nursing, Richmond, Virginia, USA
  1. Correspondence to Dr Izabella Uchmanowicz; izabella.uchmanowicz{at}


Objectives To develop a Polish adaptation of the Perceived Implicit Rationing of Nursing Care (PIRNCA)questionnaire.

Design Cross-sectional validation study.

Settings Nurses working in surgical and cancer wards in Poland.

Participants A sample of 513 professionally active nurses was enrolled in the study.

Intervention To complete a Polish translation of the full original PIRNCA questionnaire.

Primary and secondary outcome measures The primary outcome was translation and adaptation of the full original PIRNCA tool and its validation to the Polish conditions. The secondary outcome was determination of relationships between sociodemographic variables, nurses’ assessment of patient care quality and their overall job satisfaction on the one hand, and PIRNCA scores on the other.

Results The respondents’ mean score was 1.27 points (SD=0.68) on a scale from 0 to 3. Cronbach’s alpha for the entire instrument was 0.957. All items of the questionnaire were found to have a positive item-total correlation. The developed linear regression model showed that nurses’ assessment of patient care quality and their overall job satisfaction were independent predictors of PIRNCA scores (p<0.05). 94.15% of nurses reported rationing at least one of the 31 care activities.

Conclusions The present findings indicate a high level of reliability and validity of the translated PIRNCA questionnaire, fully comparable to that of the original. The questionnaire can be used for the assessment of PIRNCA in Polish hospitals.

  • care rationing
  • PIRNCA questionnaire
  • adaptation
  • psychometric evaluation

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Strengths and limitations of this study

  • This study is the first to translate and validate the Perceived Implicit Rationing of Nursing Care (PIRNCA) questionnaire in Poland.

  • We used international standards for validating and adopting the PIRNCA questionnaire.

  • This study is the first step in assessing the rationing of nursing care in Polish hospitals.

  • All data used in this study were self-reported, including surgical and cancer wards.

  • The study was conducted only in two university hospitals in Poland.


Nursing consists of providing any and all health services (ie, care, assistance, health promotion and education, etc). required by a patient, to an extent depending on the patient’s condition as determined in the Nursing Diagnosis Process.1 Sadly, multiple studies on nursing conducted in recent years2–12 demonstrated the occurrence of the phenomenon of the non-performance or incomplete or delayed performance of tasks involved in providing holistic care for a hospitalised patient.

In literature, we can meet the differences terms to describe this phenomenon—nursing care left undone,13 unfinished nursing care,14 missed nursing care,6 implicit care rationing,5 15 task incompletion,16 unmet nursing care needs,17 care left undone,18 work left undone,19 nursing tasks left undone,20 failure to maintain21 or the unfinished task of nursing care.22 All of them describe the situation when patients do not get enough care and attention which they require so in consequence, we observe that the overall process of care has adverse outcomes for patients.23

In this study, we want to validate the Perceived Implicit Rationing of Nursing Care (PIRNCA)—a tool that assesses the care rationing in nursing practice. The first time phenomenon of implicitly of care rationing was developed by Schubert from Switzerland in 2007.15 She described the conceptual framework to explain implicitly of rationing care and created a new tool (Basel Extent Rationing of Nursing Care, BERNCA) to measure this phenomenon in practice. In 2014, Jones24 from the USA adopted this instrument and next, she presented a new questionnaire PIRNCA, which was validated by surgical nurses.

Care rationing occurs when resources are insufficient (typically due to staff shortages or lack of the required materials)5 7 9 or when the so-called ‘patient safety climate’ is not ensured.9 It is measured by the number of omitted or withheld nursing activity, which should be done. Patients are also more aware of their rights, as well as of nursing and treatment methods, which creates demand for more time and energy—and in a setting of nursing staff shortages, this may also result in some patient needs not being met.25 As one can see, care rationing is contributed to by a number of factors, related to the employer, the employee and the patient (ie, characteristics of the hospital—budgets, number of beds), the employee (ie, skills, expertise of the staff, education level) and the patient (ie, type of diseases, severity, comorbidities).2 3 6 7 9 10 25

Alarmingly, studies performed so far demonstrated a detrimental impact of care rationing on treatment and nursing outcomes, including a higher mortality rate, more falls during hospitalisation and more reported hospital-acquired infections and bedsores and lower patients satisfaction.4 5 26–28

Rationing on nursing care also influences on staff outcomes. Kalisch et al29 found that nurses who reported more missed care were less satisfied with their job and occupation. Also, Bekker et al20 reported that the highest degree of job dissatisfaction is contacted with nursing tasks left undone. Tschannen et al30 reported that nurses who more frequent missed care were more tend to leave and turnover. Zeleniková et al31 shown that unfinished care correlated with overall job satisfaction and intention to leave the actual workplace.

To date, several questionnaires have been developed to assess the extent of care rationing,15 24 32 though none of these were available in Polish, and therefore, could not be used to evaluate this issue in Polish hospitals reliably.

The purpose of the study was to develop a Polish version of the PIRNCA questionnaire and to evaluate its psychometric properties concerning the assessment of the PIRNCA among Polish nurses.

Materials and methods

Study group and settings

The present cross-sectional validation study with convenience sampling and a survey method of data collection was performed between April and July 2018. The PIRNCA questionnaire was distributed among 700 nurses working in surgical and cancer wards in two public university clinical hospitals. These hospitals are located within two neighbouring regions of Poland, namely the Silesian Region (the city of Katowice) and the Lower Silesia Region (the city of Wrocław). Each of the hospitals has about 600 beds. In the first hospital, questionnaires were distributed among nurses in four surgical and oncological wards, while in the second one, in eight different surgical and oncological wards. Each ward has about 40 beds.

Qualification procedure

Inclusion criteria were: at least 1 year of experience working in a surgical or cancer ward, and provision of informed consent to participate in the study. Exclusion criteria were: work in a management position and lack of consent to participate. The final study group included 513 nurses (survey return rate: 73%). Respondents’ mean age was 42.33±7.8 years, and their mean work experience was 19.77±9.25 years. Most of the studied nurses had bachelor’s degrees (87.52%) and were employed full time (91.81%). Participation was strictly anonymous and voluntary, and all participants were informed about the study purpose.

Patient and public involvement

Neither patients nor public were involved in the design or planning of this study.

All participants who were included in the study gave written informed consent after a thorough explanation of the procedures involved.

Research tool

The PIRNCA questionnaire derives from the BERNCA Questionnaire, which was created by Schubert in 2007 in Switzerland.24 The original version of BERNCA contains 20 statements which were divided into five domains–the activity of daily livings, caring support, rehabilitation—instruction—education, monitoring—safety and documentation.15 Later the instrument was revised—now it contains 32 Likert type questions (BERNCA-R).9

The PIRNCA questionnaire comprises 31 statements describing nursing activities that the respondents could not complete due to insufficient resources (ie, staff or time shortages) during their last seven shifts. Each item in the PIRNCA questionnaire is on a scale of 0–3, where 0 is ‘never’, 1 is ‘rarely’, 2 is ‘sometimes’ and three is ‘often’, and the total result, that is, the assessment of care rationing rate, is the average of the items If none of the patients assigned to a nurse during these seven shifts required the relevant activity, the respondent should mark ‘not applicable’. The final PIRNCA score is the mean score for all questions where a scored answer has been chosen (ie, questions marked ‘not applicable’ are excluded). Thus, the total score ranges between 0 and 3, and may be interpreted as follows: higher scores indicate more implicit rationing of nursing care. The questionnaire also includes two additional questions. One concerns the nurses’ assessment of patient care. It is scored between 1 and 10 using a Likert-type scale, where 1 indicates the dangerously low quality of care, whereas 10 indicates very good quality of care. The other question concerns overall job satisfaction. Again, the response is provided using a 10-item Likert-type scale, where 1 means ‘it’s terrible’, while 10 means ‘I love it’ (online supplementry appendix 1).

Translation and language adaptation

The language validation procedure was carried out following published guidelines,33–35 following formal, written approval by the original author. The questionnaire was translated into Polish by two independent translators. The two versions were verified and corrected by a designated expert, fluent in English and having specialist knowledge on nursing terminology, thus producing a Polish version of the questionnaire that was then back-translated into English. The back-translations were compared with the original to check whether the Polish translation adequately reflects the meaning of the English original. As the meanings of each item remained the same as in the original, the translated questionnaire was used in a pilot study with a representative sample.

The adaptation was performed using the standard methodology. The Polish adaptation is based on the English-language version of the scale. Having received the authors’ approval, the questionnaire was translated into Polish by two independent translators. Then, the translations were evaluated by a panel of experts, which comprised a cardiologist, a general practitioner, two specialist cardiology nurses and a psychologist. The panel verified the phrasing and meaning of all questions, as well as the clarity and correctness of the instructions. The version selected by the panel subsequently underwent back-translation and the result was submitted for approval by the authors of the original English version. Once approved, the preliminary version was used in a pilot study on a group of 30 nurses. The pilot study resulted in the final Polish version of the PIRNCA questionnaire, validated in the present study.

Statistical analysis

The analyses were performed using the R V. Five hundred and thirteen participant’s responses were analysed. Comrey and Lee37 to suggest a sample size of 500 participants as a ‘very good’ rule of thumb for Confirmatory Factor Analysis (CFA). Internal consistency was assessed using Cronbach’s alpha and dimensionality was examined by assessing goodness of fit statistics and dimensionality was examined by assessing goodness of fit statistics and loadings on a unidimensional factor analysis model CFA (ie, all items loading onto a single latent factor).

For the CFA, Hu and Bentler’s38 methods and associated cut-offs were used. Since the PIRNCA items are expressed on an ordinal rather than continuous scale, diagonally weighted least squares weighted was used for model estimation.

Multivariate analysis of the independent impact of the studied variables on the quantitative variable was performed using linear regression. The results are shown as regression model parameter values with a 95% CI. Variable distribution normality was verified using the Shapiro-Wilk test. All analyses used a significance threshold of 0.05.


The study included 513 nurses working in surgical and cancer wards in hospitals in Silesia and Lower Silesia, Poland. Table 1 shows the participants’ characteristics.

Table 1

Respondents’ characteristics


The CFA was performed for internal consistency and demonstrated the following parameters: root mean square error of approximation=0.06; Comparative Fit Index=0.981; Tucker-Lewis index=0.98; standardised root mean square residual=0.088 and the loadings (or CFA-implied item-total correlations) of individual items ranged from 0.532 to 0.753 (table 2), which were statistically significant (p<0.05). The values of the fit statistics and the strong loadings on the main factor are in line with a unidimensional interpretation for the tool’s Polish adaptation.

Table 2

Confirmatory factor model loadings of individual items of the PIRNCA tool


Missing data

The missing data rates for specific items ranged from 0.6% (item 1) to 4.1% (item 27). The overall missing data rate was 2.24%. Detailed data are shown in table 3.

Table 3

Distribution of answers by question (%)

Total score distribution

The mean score was 1.27 (SD=0.68), indicating that care tended to be rationed ‘rarely’ rather than ‘sometimes’. The median score was 1.29 points, that is, half of the respondents scored below, and half scored above 1.29 points. The first and third quartile were 0.73 and 1.77 points, respectively, that is, standardised scores in the studied group ranged between 1.37 and 1.77 points. It was also shown that the percentage of nurses who neglect at least one activity is high and amounts to 94.15%. The average number of points for assessing the quality of care was 6.50 (SD=2.10) out of 10, which means that nurses highly evaluate the quality of the services they provide. The average score for job satisfaction was 5.49 (SD=2.19), which means that the nurses surveyed are satisfied with their current job.

The analysis of the study material showed that the PIRNCA score does not correlate (p>0.05) with the studied sociodemographic variables (age, gender, seniority, education, specialisation). On the other hand, the level of care rationing significantly correlates with the nursing evaluation of the quality of patient care (r=−0.492, p<0.005) and the evaluation of job satisfaction (r=−0.375, p<0.001). This means that the higher the subjective assessment of the quality of nursing services and the assessment of job satisfaction, the lower the level of rationing of care is observed. Also, the linear regression model showed that independent predictors of PIRNCA score are (p<0.05): nursing evaluation of the quality of patient care (each additional point decreases PIRNCA score by 0.131 points on average) and overall job satisfaction (each additional point decreases PIRNCA score by 0.04 points on average). Detailed data are presented in table 4.

Table 4

Analysis of linear regression of the PIRNCA score


The analysis performed for all items in the Polish version of the PIRNCA questionnaire yielded a Cronbach’s alpha value of 0.957 for the entire scale, indicating high reliability. All items were found to have a positive item-total correlation, meaning that they correlated positively with the remaining items of the scale, which is a very desirable characteristic. Detailed data are shown in table 5.

Table 5

Interscale correlations for PIRNCA items


Studies performed so far demonstrated that nursing care rationing is a serious issue, present in Western European states,2 4 5 8 9 the USA10 11 24 27 and Australia.12 All these countries are highly developed and have incomparably higher healthcare spending than Poland,39 possibly suggesting that problems with resource allocation or staff shortages may be less severe there than in Poland. Therefore, the development of a Polish version of a questionnaire measuring the PIRNCA was warranted in order to investigate this issue in Polish settings. For this purpose, the American PIRNCA questionnaire by Jones was adapted,24 as it has been demonstrated to be a valid and reliable instrument for evaluating care rationing levels in a relevant validation study.

In the present study, Cronbach’s alpha for the entire scale was 0.957, which indicates high reliability and is similar to the value reported by the original author.24 This result confirms the credibility of the Polish version of the PIRNCA questionnaire in the assessment of the phenomenon of implicit rationing of nursing care in Polish hospitals.

In Jones’s studies,24 40 respondents’ mean score was 1.12 or 1.15 (SD=0.67 or SD=0.66). The present study yielded very similar scores, indicating that care was rationed ‘rarely’. The studies24 31 40 41 showed that approximately 95%–98% of nurses indicate that they neglect at least one of the 30 listed nursing activities during patient care. A similar percentage was also obtained in this study, which means that regardless of the latitude, nurses show a lack of ability to perform all the tasks entrusted to them during the care of the patient.

In literature, the most frequently rationing nursing activity are: timeliness of response to requests,24 40 41 emotional and psychological support9 31 and comfort/talk with patients.16 18 20 In this study—the education of patients and families and emotional support were the most frequently reported nursing activity which was rationing during shift. Many authors24 31 40 41 have shown that the care activities least frequently rationed included administering enteral nutrition and medication administration which confirmed the results of this study.

In this study, the correlation between PIRNCA results and nursing evaluation of the quality of patient care (r=−0.492, p<0.005) and job satisfaction evaluation (r=−0.375, p<0.001) was also shown, which is also confirmed by the results obtained by Jones24 and Zeleniková et al.31 Although the level of care rationing is statistically significant, it revealed a fair relationship with the nursing evaluation of the quality of patient care and the evaluation of job satisfaction.42

The main strength to be drawn from this study is that the PIRNCA is a very useful tool when monitoring the phenomenon of rationing nursing care, including the identification of care activities that are more often omitted. Expanding knowledge in this area, the PIRNCA can support nurse managers’ efforts to facilitate the process of nursing care. It is anticipated that the PIRCNA tool will be useful in reducing negative effects of care left undone for patients and nurse practitioners.


This study has some potential methodological limitations to be mentioned. The primary limitation is that all data used in this study were self-reported, which is one of the most widely used methods of collecting data in terms of patients’ state of health, their assessment of the quality of health services, but also the assessment of medical personnel in various aspects of their professional work; however, flawed and with potential risk of bias. Furthermore, the study was conducted only in two university hospitals in the region; thus, it is difficult to generalise the findings on the entire population of nurses in Poland; thus, our findings should be interpreted with caution. Finally, another limitation that should be considered is relatively small sample size; however, the sample size was calculated and it was similar to the original validation study.


The main practical implication of this study is that the PIRNCA is a very useful instrument for monitoring the level of rationing of nursing care including identification of nursing activities which are omitted more often. The knowledge about this phenomenon and its reasons can help nurse managers’ to take action in improving the process of nursing care. It is anticipated that the PIRNCA tool will be useful in the reduction of negative patients and nurses’ outcomes. We recommend further research on the rationing of nursing care; thanks to Polish adaptation it will be possible among Polish nurses. Rationing of nursing care is a plaque of today's times resulting from shortages of nursing staff. That is why it is so important to be able to continue research in this area.


The present study was the first to translate and validate the PIRNCA questionnaire in Polish nurses. Our results show that the Polish version of the PIRNCA questionnaire is a reliable and valid instrument for monitoring the extent of nursing care rationing in Polish hospital wards. The validation and adaptation of PIRNCA is the first step in assessing the rationing of nursing care in Polish hospitals.


We want to thank all respondents for their contribution in this research. There were no other contributors to the article than the authors as well as there was no writing assistance regarding our paper. Certified English language services were provided by a highly qualified academic native English speaker.



  • Contributors IU, AK, KŁ, IW and JR planned the study. AM and TJ supervised the study. IU, AM, IW and TJ analysed the data. IU, AK, KŁ and JR drafted the manuscript. All authors contributed substantially to its revision. All authors read and approved the final manuscript. IU takes responsibility for the paper as a whole.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was carried out in accordance with the tenets of the Declaration of Helsinki and was approved by the independent Bioethics Committee of the Wrocław Medical University in Poland.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.