Validation of the Basel Extent of Rationing of Nursing Care instrument.

BACKGROUND Financial constraints and other forces affecting health care in many countries have led to nurses implicitly limiting their care in some instances. In the absence of an accepted definition and theoretical framework of implicit rationing of nursing care, a framework and the Basel Extent of Rationing of Nursing Care (BERNCA) instrument were developed. This instrument was used in the Swiss part of the International Hospital Outcome Study, in which implicit rationing of nursing care was studied. OBJECTIVE To examine the validity and reliability of the newly developed BERNCA instrument. METHODS Psychometric analysis was performed on data from 957 nurses in five Swiss acute care hospitals enrolled in a larger hospital organization study. An explanatory factor analysis with varimax rotation was used to investigate the instrument's internal structure, Spearman correlations were used to test relationships between implicit rationing and two related concepts, and Cronbach's alpha and interitem correlations were used to test the reliability of the scale. RESULTS Expert feedback confirmed that the BERNCA covered the implicit rationing of nursing care domain adequately and that its questions were fully comprehensible. The single-factor solution confirmed the instrument's unidimensional internal structure. A moderate to strong correlation in the expected direction was found between the BERNCA implicit rationing data and the quality of the nurse work environment as measured by the Nursing Work Index-Revised, particularly the perceived adequacy of nursing resources, although a significant but low correlation was also shown with patient-to-nurse ratios. Cronbach's alphas (.93) and interitem correlations indicated internal consistency and homogeneity. DISCUSSION Initial evidence of the validity and reliability of the BERNCA instrument was provided.