Anne Marie Rafferty

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States

Objective To determine whether hospitals with a good organisation of care (such as improved nurse staffing and work environments) can affect patient care and nurse workforce stability in European countries. Design Cross sectional surveys of patients and nurses. Setting Nurses were surveyed in general acute care hospitals (488 in 12 European countries; 617 in the United States); patients were surveyed in 210 European hospitals and 430 US hospitals. Participants 33 659 nurses and 11 318 patients in Europe; 27 509 nurses and more than 120 000 patients in the US. Main outcome measures Nurse outcomes (hospital staffing, work environments, burnout, dissatisfaction, intention to leave job in the next year, patient safety, quality of care), patient outcomes (satisfaction overall and with nursing care, willingness to recommend hospitals). Results The percentage of nurses reporting poor or fair quality of patient care varied substantially by country (from 11% (Ireland) to 47% (Greece)), as did rates for nurses who gave their hospital a poor or failing safety grade (4% (Switzerland) to 18% (Poland)). We found high rates of nurse burnout (10% (Netherlands) to 78% (Greece)), job dissatisfaction (11% (Netherlands) to 56% (Greece)), and intention to leave (14% (US) to 49% (Finland, Greece)). Patients’ high ratings of their hospitals also varied considerably (35% (Spain) to 61% (Finland, Ireland)), as did rates of patients willing to recommend their hospital (53% (Greece) to 78% (Switzerland)). Improved work environments and reduced ratios of patients to nurses were associated with increased care quality and patient satisfaction. In European hospitals, after adjusting for hospital and nurse characteristics, nurses with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval 0.51 to 0.61) and give their hospitals poor or failing grades on patient safety (0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds of nurses reporting poor or fair quality care (1.11, 1.07 to 1.15) and poor or failing safety grades (1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (1.16, 1.03 to 1.32) and recommend their hospitals (1.20, 1.05 to 1.37), whereas those with higher ratios of patients to nurses were less likely to rate them highly (0.94, 0.91 to 0.97) or recommend them (0.95, 0.91 to 0.98). Results were similar in the US. Nurses and patients agreed on which hospitals provided good care and could be recommended. Conclusions Deficits in hospital care quality were common in all countries. Improvement of hospital work environments might be a relatively low cost strategy to improve safety and quality in hospital care and to increase patient satisfaction.

Are teamwork and professional autonomy compatible, and do they result in improved hospital care?

A postal questionnaire survey of 10 022 staff nurses in 32 hospitals in England was undertaken to explore the relationship between interdisciplinary teamwork and nurse autonomy on patient and nurse outcomes and nurse assessed quality of care. The key variables of nursing autonomy, control over resources, relationship with doctors, emotional exhaustion, and decision making were found to correlate with one another as well as having a relationship with nurse assessed quality of care and nurse satisfaction. Nursing autonomy was positively correlated with better perceptions of the quality of care delivered and higher levels of job satisfaction. Analysis of team working by job characteristics showed a small but significant difference in the level of teamwork between full time and part time nurses. No significant differences were found by type of contract (permanent v short term), speciality of ward/unit, shift length, or job title. Nurses with higher teamwork scores were significantly more likely to be satisfied with their jobs, planned to stay in them, and had lower burnout scores. Higher teamwork scores were associated with higher levels of nurse assessed quality of care, perceived quality improvement over the last year, and confidence that patients could manage their care when discharged. Nurses with higher teamwork scores also exhibited higher levels of autonomy and were more involved in decision making. A strong association was found between teamwork and autonomy; this interaction suggests synergy rather than conflict. Organisations should therefore be encouraged to promote nurse autonomy without fearing that it might undermine teamwork.

‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care

Background There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure—‘missed care’. Aim To examine the nature and prevalence of care left undone by nurses in English National Health Service hospitals and to assess whether the number of missed care episodes is associated with nurse staffing levels and nurse ratings of the quality of nursing care and patient safety environment. Methods Cross-sectional survey of 2917 registered nurses working in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England. Results Most nurses (86%) reported that one or more care activity had been left undone due to lack of time on their last shift. Most frequently left undone were: comforting or talking with patients (66%), educating patients (52%) and developing/updating nursing care plans (47%). The number of patients per registered nurse was significantly associated with the incidence of ‘missed care’ (p<0.001). A mean of 7.8 activities per shift were left undone on wards that are rated as ‘failing’ on patient safety, compared with 2.4 where patient safety was rated as ‘excellent’ (p <0. 001). Conclusions Nurses working in English hospitals report that care is frequently left undone. Care not being delivered may be the reason low nurse staffing levels adversely affects quality and safety. Hospitals could use a nurse-rated assessment of ‘missed care’ as an early warning measure to identify wards with inadequate nurse staffing.

Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology

BackgroundCurrent human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care.Methods/DesignA multi-country, multilevel cross-sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences.This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce.DiscussionRN4CAST is one of the largest nurse workforce studies ever conducted in Europe, will add to accuracy of forecasting models and generate new approaches to more effective management of nursing resources in Europe.

Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study

Background Little is known of the extent to which nursing-care tasks are left undone as an international phenomenon. Aim The aim of this study is to describe the prevalence and patterns of nursing care left undone across European hospitals and explore its associations with nurse-related organisational factors. Methods Data were collected from 33 659 nurses in 488 hospitals across 12 European countries for a large multicountry cross-sectional study. Results Across European hospitals, the most frequent nursing care activities left undone included ‘Comfort/talk with patients’ (53%), ‘Developing or updating nursing care plans/care pathways’ (42%) and ‘Educating patients and families’ (41%). In hospitals with more favourable work environments (B=−2.19; p<0.0001), lower patient to nurse ratios (B=0.09; p<0.0001), and lower proportions of nurses carrying out non-nursing tasks frequently (B=2.18; p<0.0001), fewer nurses reported leaving nursing care undone. Conclusions Nursing care left undone was prevalent across all European countries and was associated with nurse-related organisational factors. We discovered similar patterns of nursing care left undone across a cross-section of European hospitals, suggesting that nurses develop informal task hierarchies to facilitate important patient-care decisions. Further research on the impact of nursing care left undone for patient outcomes and nurse well-being is required.

A systematic survey instrument translation process for multi-country, comparative health workforce studies

BACKGROUND As health services research (HSR) expands across the globe, researchers will adopt health services and health worker evaluation instruments developed in one country for use in another. This paper explores the cross-cultural methodological challenges involved in translating HSR in the language and context of different health systems. OBJECTIVES To describe the pre-data collection systematic translation process used in a twelve country, eleven language nursing workforce survey. DESIGN AND SETTINGS We illustrate the potential advantages of Content Validity Indexing (CVI) techniques to validate a nursing workforce survey developed for RN4CAST, a twelve country (Belgium, England, Finland, Germany, Greece, Ireland, Netherlands, Norway, Poland, Spain, Sweden, and Switzerland), eleven language (with modifications for regional dialects, including Dutch, English, Finnish, French, German, Greek, Italian, Norwegian, Polish, Spanish, and Swedish), comparative nursing workforce study in Europe. PARTICIPANTS Expert review panels comprised of practicing nurses from twelve European countries who evaluated cross-cultural relevance, including translation, of a nursing workforce survey instrument developed by experts in the field. METHODS The method described in this paper used Content Validity Indexing (CVI) techniques with chance correction and provides researchers with a systematic approach for standardizing language translation processes while simultaneously evaluating the cross-cultural applicability of a survey instrument in the new context. RESULTS The cross-cultural evaluation process produced CVI scores for the instrument ranging from .61 to .95. The process successfully identified potentially problematic survey items and errors with translation. CONCLUSIONS The translation approach described here may help researchers reduce threats to data validity and improve instrument reliability in multinational health services research studies involving comparisons across health systems and language translation.

Organisational change and quality of health care: an evolving international agenda.

The nature of organisational change in the health sector Healthcare reform is now on the agenda of governments in nearly all industrialised countries. Upward pressure on costs, from such factors as the consequences of new technology and rising public expectations, has collided with downward pressure from economic recession, political unwillingness to increase taxes, and, in the United States, demand for ever greater profits from the corporate providers of health care. The most frequent response to these pressures is to seek ways of limiting costs. These have concentrated largely on hospital care as hospitals continue to consume the largest portion of national health spending and it has led to a range of major changes in how hospitals are organised. These organisational changes can be thought of as falling into three broad categories relating to developments outside, within, and between hospitals. The first category considers the interface between the hospital and its external environment, seeking to shift patients currently treated in hospital to other settings. Examples include transfer of diagnostic procedures and minor surgery to ambulatory care, substitution of outpatient care for conditions previously treated on an inpatient basis—such as chronic illness, substance misuse, and depression. The second category considers the hospital’s internal environment, seeking ways to increase eYciency by redesigning work, changing staV, reducing inappropriate and thus wasteful care, and by treating patients in less resource intensive ways. Examples include changes in the skill mix of staV, substituting workers with less training for registered nurses, and reductions in ancillary services, intensive care days, and overall duration of stay. The third category relates to the relations between hospitals, asking whether existing configurations of hospital services oVer the optimal balance between eVectiveness and eYciency on the one hand and accessibility on the other. Examples include mergers of specialist units in neighbouring hospitals, regionalisation of services, and the development of outreach services. In theory, all of these strategies oVer scope to reduce the cost of providing a given package of care while maintaining, or even improving, quality. In practice, however, commentators are increasingly questioning whether this is happening. 4 Three main concerns have been voiced. Firstly, can the proposed changes deliver what they set out to? For example, is there empirical evidence that a shift of particular types of patients from hospital to primary care can both reduce costs, and at least maintain quality? Secondly, is organisational change actually being pursued with the aim of reducing costs regardless of quality, with managers concentrating on presentation rather than real changes in quality of care? Thirdly, do the organisational changes being pursued have adverse implications for quality of care by, for example, disrupting existing structures and relations? Questions about the evidence underpinning these strategies form an enormous topic which cannot be dealt with adequately in the space available. There are, however, several recent reviews—such as those listed on the Cochrane database—considering specific questions— such as whether the outcome of care is improved by centralising specialist services or whether specific services are best delivered in hospital or in the community. There are four main messages from this research literature. Firstly, it should not be assumed that simply moving a service out of hospital will reduce costs. Secondly, there are still many gaps in our knowledge of what does or does not work. Thirdly, such changes should be actively managed rather than left to happen by default. And fourthly, there are many unresolved issues about whether policies found to be beneficial in one setting can be transferred to another. Concerns about the pursuit of cost savings at the expense of quality also will not be dealt with here, although it is important to note that the magnitude of change in some countries has raised fears about undesirable trade oVs being made. This is most obvious in the United States where federal and state legislatures have recently laid down minimum hospital stays after giving birth and limited the ability of hospitals to perform complex procedures such as mastectomies as day cases. These concerns have also led some commentators to view strategies such as total quality management or continuous quality improvement as tools that are primarily designed to “downsize” hospital Quality in Health Care 1998;7:37–41 37

Nurses' shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety

Background:Despite concerns as to whether nurses can perform reliably and effectively when working longer shifts, a pattern of two 12- to 13-hour shifts per day is becoming common in many hospitals to reduce shift to shift handovers, staffing overlap, and hence costs. Objectives:To describe shift patterns of European nurses and investigate whether shift length and working beyond contracted hours (overtime) is associated with nurse-reported care quality, safety, and care left undone. Methods:Cross-sectional survey of 31,627 registered nurses in general medical/surgical units within 488 hospitals across 12 European countries. Results:A total of 50% of nurses worked shifts of ⩽8 hours, but 15% worked ≥12 hours. Typical shift length varied between countries and within some countries. Nurses working for ≥12 hours were more likely to report poor or failing patient safety [odds ratio (OR)=1.41; 95% confidence interval (CI), 1.13–1.76], poor/fair quality of care (OR=1.30; 95% CI, 1.10–1.53), and more care activities left undone (RR=1.13; 95% CI, 1.09–1.16). Working overtime was also associated with reports of poor or failing patient safety (OR=1.67; 95% CI, 1.51–1.86), poor/fair quality of care (OR=1.32; 95% CI, 1.23–1.42), and more care left undone (RR=1.29; 95% CI, 1.27–1.31). Conclusions:European registered nurses working shifts of ≥12 hours and those working overtime report lower quality and safety and more care left undone. Policies to adopt a 12-hour nursing shift pattern should proceed with caution. Use of overtime working to mitigate staffing shortages or increase flexibility may also incur additional risk to quality.

Impact of organisation and management factors on infection control in hospitals: a scoping review

This scoping review sought evidence about organisational and management factors affecting infection control in general hospital settings. A literature search yielded a wide range of studies, systematic reviews and reports, but high quality direct evidence was scant. The majority of studies were observational and the standard of reporting was generally inadequate. Positive leadership at ward level and above appears to be a prerequisite for effective action to control infection, although the benefits of good clinical leadership are diffused by supervision of large numbers of staff. Senior clinical leaders need a highly visible presence and clear role boundaries and responsibilities. Team stability and morale are linked to improved patient outcomes. Organisational mechanisms for supporting training, appraisal and clinical governance are important determinants of effective practice and successful change. Rates of infection have been linked to workload, in terms of nurse staffing, bed occupancy and patient turnover. The organisational characteristics identified in the review should be considered risk factors for infection. They cannot always be eliminated or avoided completely, but appropriate assessment will enable targeted action to protect patients.

Nurse staffing, medical staffing and mortality in intensive care: an observational study

OBJECTIVES To investigate whether the size of the workforce (nurses, doctors and support staff) has an impact on the survival chances of critically ill patients both in the intensive care unit (ICU) and in the hospital. BACKGROUND Investigations of intensive care outcomes suggest that some of the variation in patient survival rates might be related to staffing levels and workload, but the evidence is still equivocal. DATA Information about patients, including the outcome of care (whether the patient lived or died) came from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. An Audit Commission survey of ICUs conducted in 1998 gave information about staffing levels. The merged dataset had information on 65 ICUs and 38,168 patients. This is currently the best available dataset for testing the relationship between staffing and outcomes in UK ICUs. DESIGN A cross-sectional, retrospective, risk adjusted observational study. METHODS Multivariable, multilevel logistic regression. OUTCOME MEASURES ICU and in-hospital mortality. RESULTS After controlling for patient characteristics and workload we found that higher numbers of nurses per bed (odds ratio: 0.90, 95% confidence interval: [0.83, 0.97]) and higher numbers of consultants (0.85, [0.76, 0.95]) were associated with higher survival rates. Further exploration revealed that the number of nurses had the greatest impact on patients at high risk of death (0.98, [0.96, 0.99]) whereas the effect of medical staffing was unchanged across the range of patient acuity (1.00, [0.97, 1.03]). No relationship between patient outcomes and the number of support staff (administrative, clerical, technical and scientific staff) was found. Distinguishing between direct care and supernumerary nurses and restricting the analysis to patients who had been in the unit for more than 8h made little difference to the results. Separate analysis of in-unit and in-hospital survival showed that the clinical workforce in intensive care had a greater impact on ICU mortality than on hospital mortality which gives the study additional credibility. CONCLUSION This study supports claims that the availability of medical and nursing staff is associated with the survival of critically ill patients and suggests that future studies should focus on the resources of the health care team. The results emphasise the urgent need for a prospective study of staffing levels and the organisation of care in ICUs.