1. Introduction
The nursing process is the basis for maintaining the health and life of patients. Nurses, who represent a significant proportion of healthcare professionals, are responsible for its implementation. Practicing as a nurse has a significant impact on the quality of healthcare. Nurses are a professional group that, in their work, establish contact not only with the patient but also with his/her family, as well as other members of the therapeutic team [
1,
2]. The work of a nurse is associated with a high level of psychosocial risk, which results from the specificity of the profession, which is multi-tasking and complex [
3]. The nursing profession is autonomous, and nurses are responsible for carrying out many tasks, such as nursing care, health promotion and rehabilitation. Although the nursing profession, its functions and tasks are clearly defined, the specificity of each ward affects the level of stress, occupational burnout and the level of requirements [
4]. Work in the surgical ward requires from nurses: physical strength, mental resistance, constant concentration and the ability to make quick decisions [
3]. The psychosocial factors influencing the work of a nurse include: high pace of work, low level of autonomy, workload, working hours, organizational culture, interpersonal relations with other employees, career development, job security, role conflict and job satisfaction [
5]. Working as a nurse and helping other people requires emotional involvement. Working in an environment of human suffering has a particularly negative impact on caregivers, leading to fatigue, frustration and burnout [
6]. A consequence of exposure to psychosocial factors is stress. Short periods of stress may have an adaptive function, while long-term stress may lead to somatic diseases and occupational burnout [
7].
The nursing profession includes close and intense contact with other people. Involvement in work, care and responsibility for patients, constant changes, stress, working under time pressure are factors that particularly expose nurses to occupational burnout. The term was first used by the American psychiatrist Freundenberg, and then Maslach and Jackson, created a multidimensional definition, where burnout is a “psychological syndrome of emotional exhaustion, depersonalization and a reduced sense of personal achievement that can occur in people who work with other people in a certain way”. Burnout can manifest itself as a subjective symptom of high mental strain and lack of strength to work, as well as a hostile attitude towards other people and a feeling of dissatisfaction with work and having competences. The opposite issue related to professional burnout is job satisfaction, which can be defined as the relationship between investment in oneself, i.e., education, improvement of qualifications and commitment to work, and its effect, i.e., what the nurse receives, e.g., gratification, promotion and praise [
8,
9].
Fatigue can be characterized as a decrease in exercise capacity, which is manifested by a decrease in the intensity and efficiency of work [
10]. It is associated with a sense of depressing fatigue and lack of energy, as well as a sense of lack of strength, which results from a physical and/or cognitive dysfunction of the body. In the work of a nurse, fatigue may lead to such consequences as low self-esteem, avoidance of contact with patients and many others, which may have a negative impact on the well-being and functioning in the professional and private sphere [
11]. All these factors can lead to the care rationing phenomenon.
As a result of insufficient resources and pressing tasks, nurses have difficulty or are unable to complete the activities set out in the individual nursing care plan. Therefore, there are situations when they can shorten, postpone or completely abandon certain activities [
12]. Rationing generally means that the trade-offs of resource scarcity are embedded in the decision-making process, with the result that necessity-driven care rationing will result in sub-optimal resource exclusion or benefit for some recipients [
13]. On the other hand, rationing in healthcare can be defined as an informed and justified decision of the service provider to refuse access to medical services that extend life or medical services that may help restore or alleviate severe dysfunctions in some patients in the event of an irreversible shortage of resources. Due to this rationing assumption, medical activities are desirable and effective [
14]. The attention to this problem was first raised in 2006 by the American nurse Beatrice J. Kalisch et al. [
15], who created the concept of loss of nursing care, referred to as the omission error, and which refers to all areas of required patient care that have been partially or completely omitted [
16]. Nursing care rationing is defined as the incomplete or non-performance of the necessary nursing activities during on-call time. It occurs when necessary care cannot be provided to patients because resources are scarce [
15]. Rationing can be divided into two types, institutional and individual. Institutional rationing is manifested in the form of a specific policy of a given institution, and it is imposed on employees, e.g., nurses, doctors. On the other hand, the individual one is left for individual people and does not have specific normative foundations, rules and instructions for action. Rationing requires an individual decision in terms of metrics and ethics, which may involve providing the patient with less than optimal care. Often, the lack of involvement of the nurse in making decisions about rationing may indicate that rationing takes place at the patient’s “bedside” and that the nurse is not aware of the rationing decisions made. In the case of a deliberate rationing decision, it is burdensome for the nurse because it is morally problematic in nature [
13]. Nurses’ personal confrontation with decisions about rationing care is related to the feeling of moral anxiety [
17]. The reasons for rationing care include a reduction in employment, increased demand for care related to new technologies and new treatment methods, as well as the increasing level of knowledge and expectations of patients, which generates more work and time for care. The reasons for this occurrence include the selected attitudes of nurses, their knowledge and clinical evaluation during care, which may result in insufficient activities [
18]. Winsett et al. identified six possible causes of the care rationing phenomenon, i.e., unexpected increase in the number of patients, increased frequency of discharges and admissions, inadequate assistants, inadequate staff, lack of availability of drugs when urgently needed and emergencies [
19]. The phenomenon of rationing care is also influenced by aspects related to the nurses themselves, such as a decreased level of job satisfaction, increased level of stress, the occurrence of occupational burnout, increased absenteeism and staff turnover [
20,
21], in addition to factors independent of nurses, such as the work environment and culture, organizational resources, philosophy of care and model of care, as well as the financial resources allocated to the implementation of nursing care [
22,
23]. Prioritizing on the basis of professional clinical judgment in nursing care can be a cause of neglect as well as a negative impact on the entire therapeutic process [
24].
The problem of rationing nursing care is common and present all over the world, which is a direct threat to the health and life of patients. In addition, the problems of health protection with a shortage of nurses and care and its omission are a general threat that may lead to the occurrence of medical errors [
25]. The rationing of nursing care, and most of all the results, contradict the principles of holistic nursing care and lower the quality of services provided by nurses [
26].
There are many studies on rationing nursing care, mostly in intensive care units or surgery units in general, for example, the research by Jankowska-Polańska et al. in the departments of hematology and pediatric oncology, where the level of rationing is high in nurses working 12 h shifts, and the level of fatigue was high in all subjects [
27]. The study by Rochefort et al. in the neonatal intensive care unit showed that 28% (often) and 40% (very often) of nurses rationally prepare for discharge and provide comfort to infants [
24]. Schubert’s research on surgical, gynecological and conservative departments showed that nurses rarely ignored the performance of their tasks [
18]. The research of Młynarska et al. in intensive care units showed that care is rarely rationalized [
11]. Studies related only to urology units are missing, which contributed to the creation of the following study. Although the nursing profession and its functions and tasks are clearly defined, the specificity of each ward affects the level of stress, occupational burnout and the level of requirements [
4]. Work in the surgical ward requires such requirements as physical strength, mental resistance, constant concentration and the ability to make quick decisions [
3].
Nurses working in urology departments must have detailed knowledge of the anatomy and physiology of the urogenital system of both men and women. They must have knowledge and skills enabling them to carry out the necessary procedures to care for patients in clinics and at home, performing preventive tasks, e.g., education, instruction, diagnostics (e.g., conducting uroflavometry and surgical tests, such as catheterization, suture removal), as well as caring for the sick. In urological wards, where care is mainly based on perioperative care and preparation for functioning at home. Preparing the patient to leave the hospital is a very time-consuming process that begins after the patient is admitted to the ward. Depending on the type of disease, the nurse has to educate the patient about diet, hygiene, changing stoma bags, possible side effects and the course of the perioperative process itself [
28,
29]. In addition, a nurse working in the urology department has contact with the most intimate sphere of a person, which requires an appropriate psychological approach to the patient and high precision during the procedures performed, as well as empathy and understanding. The ability to support the patient is of key importance, and above all, openness when talking to the patient about his intimate and sexual sphere.
Psychosocial factors cause stress in nurses, which in turn, in combination with fatigue, can affect job satisfaction and the risk of burnout, which may be transferred to the quality of patient care and the level of care rationing. The relationships between fatigue, job satisfaction, professional burnout and care rationing may be different for each nurse and of a different intensity; however, in our study, the research will be limited and averaged to the group of urological nurses.
The main aim of the study was to examine the level of rationing in nursing care, occupational burnout, fatigue and job satisfaction among nurses working in urology departments. Additionally, specific aims were set, such as: (1) the relationship between the age of the respondents and the level of care rationing, job satisfaction and professional burnout; (2) the relationship between work experience in general and work experience in the urology department and the level of care rationing, job satisfaction and professional burnout; (3) the relationship between the number of jobs and the level of job satisfaction and occupational burnout; and (4) the relationship between the level of fatigue and care rationing, the level of job satisfaction and occupational burnout.