Ingeborg Strømseng Sjetne

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 33u2009659 nurses and 11u2009318 patients in Europe; 27u2009509 nurses and more than 120u2009000 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.

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 33u2005659 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.

Nurses' intention to leave their profession: A cross sectional observational study in 10 European countries

BACKGROUNDnAs the European population ages, the demand for nursing care increases. Yet, a shortage of nurses at the labour market exists or is predicted for most European countries. There are no adequate solutions for this shortage yet, and recruitment of future nurses is difficult. Therefore, retaining nurses for the profession is urgent.nnnOBJECTIVEnTo determine factors associated with nurses intention to leave the profession across European countries.nnnDESIGNnA multi-country, multi-centre, cross-sectional analysis of survey data.nnnSETTINGn2025 surgical and medical units from 385 hospitals in ten European countries that participated in the RN4Cast study. Hospital selection was based on a stratified randomised selection procedure.nnnPARTICIPANTSnAll nurses from the participating medical and surgical hospital wards received a survey. 23,159 nurses (64%) returned the survey.nnnMETHODSnThe nurse survey included questions about intention to leave the profession, nurse characteristics, factors related to work environment, patient-to-nurse staffing ratio, burnout and perceived quality and safety of care. Multilevel regression analyses with intention to leave the profession as dependent variable were conducted for all 10 countries combined as well as per country.nnnRESULTSnOverall, 9% of the nurses intended to leave their profession. This varied from 5 to 17% between countries. Seven factors were associated with intention to leave the profession at European level: nurse-physician relationship (OR 0.86; 95%CI 0.79-0.93), leadership (OR 0.78; 95% CI 0.70-0.86), participation in hospital affairs (0.68; 95%CI 0.61-0.76), older age (OR 1.13; 95%CI 1.07-1.20), female gender (OR 0.67; 95%CI 0.55-0.80), working fulltime (OR 0.76; 95%CI 0.66-0.86) and burnout (OR 2.02; 95%CI 1.91-2.14). The relevance of these factors differed for the individual countries. Nurse perceived staffing adequacy, patient-to-nurse staffing ratio, perceived quality and safety of care and hospital size were not associated with intention to leave at a European level.nnnCONCLUSIONnBurnout is consistently associated with nurses intention to leave their profession across the 10 European countries. Elements of work environment are associated with intention to leave the nursing profession but differ between countries, indicating the importance of national contexts in explaining and preventing nurses intention to leave their profession.

Overall patient satisfaction with hospitals: effects of patient-reported experiences and fulfilment of expectations

Background Patient satisfaction and experiences are important parts of healthcare quality, but patient expectations are seldom included in quality assessments. The objective of this study was to estimate the effects of different predictors of overall patient satisfaction with hospitals, including patient-reported experiences, fulfilment of patient expectations and socio-demographic variables. Methods Data were collected using a national patient-experience survey of 63 hospitals in the five health regions in Norway during the autumn of 2006. Postal questionnaires were mailed to 24u2008141 patients after their discharge from hospital. Non-respondents were sent a reminder after 4u2005weeks. Multivariate linear regression analysis including multilevel regression was used to assess the predictors of overall patient satisfaction with hospitals. Results Thirteen variables were significantly associated with overall patient satisfaction: two variables about fulfilment of expectations, eight about patient-reported experiences and three socio-demographic variables. The regression model explained 59% of the variation in overall patient satisfaction. The most important predictor of patient satisfaction with hospitals was patient-reported experiences with the nursing services (β=0.27, p<0.001), followed by fulfilment of patient expectations (β=0.21, p<0.001), experiences with doctor services (β=0.12, p<0.001) and perceived incorrect treatment (β=−0.12, p<0.001). Multilevel regression analysis confirmed most of the findings, but revealed that age was not a significant predictor of overall patient satisfaction. Conclusions The study showed that both fulfilment of expectations and patient-reported experiences are distinct from but related to overall patient satisfaction. The most important predictors for overall patient satisfaction with hospitals are patient-reported experiences and fulfilment of expectations.

The effect of hospital size and teaching status on patient experiences with hospital care: a multilevel analysis.

Background:Hospitals rapidly change structure and organization. Little research has been conducted that documents whether hospital size and teaching status is associated with patient experiences. Objectives:We sought to assess the effect of hospital size and teaching status on patient experiences with hospital care. Methods:We undertook a cross-sectional survey of patients discharged from somatic hospitals in Norway. Multilevel regression analysis was used to assess the effect of interest. A total of 21,445 patients from 50 hospitals, categorized as small (36–85 beds, n = 17), medium-sized (88–218 beds, n = 17), large, nonteaching hospitals (226–725 beds, n = 10), and large, teaching hospitals (380–997 beds, n = 6) were studied. We used the Patients’ Experiences Questionnaire (PEQ), which contains 10 scales measuring different aspects of hospital care. Results:In general, the 10,626 respondents (50% response) rated their experiences as positive. Intraclass correlation ranged from 0.23% (Scale Information About Examinations) to 6.5% (Scale Hospital and Equipment), indicating that a small to modest proportion of the variance was at the hospital level. On 5 of the 10 PEQ scales, a statistically significant part of the variance between hospitals was attributed to hospital category. Small hospitals received the highest ratings and large, teaching hospitals the lowest. Patient characteristics and hospital category contributed together to a proportional reduction in variance ranging from 7.6% (Hospital and Equipment scale) to 53.1% (Hospital Organization scale). Conclusion:The effect of hospital category on patient experiences with hospital care was small. Hospital category was not a major determinant of patient experiences during hospitalization.

There's No Place Like Home: A Scoping Review on the Impact of Homelike Residential Care Models on Resident-, Family-, and Staff-Related Outcomes

BACKGROUNDnThere is increasing emphasis on promoting homelike residential care models enabling care-dependent people to continue living in a self-determined manner. Yet, little is known about the outcomes of homelike residential care models.nnnPURPOSEnWe aimed to (1) identify homelike residential care models for older care-dependent people with and without dementia, and (2) explore the impact of these models on resident-, family-, and staff-related outcomes.nnnDESIGN AND METHODSnWe applied a scoping review method and conducted a comprehensive literature search in PubMed, Embase, and CINAHL in Mayxa02015.nnnRESULTSnWe included 14 studies, reported in 21 articles. Studies were conducted between 1994 and 2014, most using a quasi-experimental design and comparing the Eden Alternative (nxa0=xa05), nondementia-specific small houses (eg Green House homes) (nxa0=xa02), and dementia-specific small houses (nxa0=xa07) with usual care in traditional nursing homes. The studies revealed evidence of benefit related to physical functioning of residents living in dementia-specific small houses and satisfaction with care of residents living in nondementia-specific small houses compared with those living in traditional nursing homes. We did not find other significant benefits related to physical and psychosocial outcomes of residents, or in family- and staff-related outcomes.nnnIMPLICATIONSnThe current evidence on homelike residential care models is limited. Comparative-effectiveness research building on a clear theoretical framework and/or logic model and including a standardized set of resident-, family-, and staff-related outcomes, as well as cost evaluation, is needed to provide a stronger evidence base to justify the uptake of more homelike residential care models.

The Generic Short Patient Experiences Questionnaire (GS-PEQ): identification of core items from a survey in Norway

BackgroundQuestionnaires are commonly used to collect patient, or user, experiences with health care encounters; however, their adaption to specific target groups limits comparison between groups. We present the construction of a generic questionnaire (maximum of ten questions) for user evaluation across a range of health care services.MethodsBased on previous testing of six group-specific questionnaires, we first constructed a generic questionnaire with 23 items related to user experiences. All questions included a not applicable response option, as well as a follow-up question about the items importance. Nine user groups from one health trust were surveyed. Seven groups received questionnaires by mail and two by personal distribution. Selection of core questions was based on three criteria: applicability (proportion not applicable), importance (mean scores on follow-up questions), and comprehensiveness (content coverage, maximum two items per dimension).Results1324 questionnaires were returned providing subsample sizes ranging from 52 to 323. Ten questions were excluded because the proportion of not applicable responses exceeded 20% in at least one user group. The number of remaining items was reduced to ten by applying the two other criteria. The final short questionnaire included items on outcome (2), clinician services (2), user involvement (2), incorrect treatment (1), information (1), organisation (1), and accessibility (1).ConclusionThe Generic Short Patient Experiences Questionnaire (GS-PEQ) is a short, generic set of questions on user experiences with specialist health care that covers important topics for a range of groups. It can be used alone or with other instruments in quality assessment or in research. The psychometric properties and the relevance of the GS-PEQ in other health care settings and countries need further evaluation.

Service quality in hospital wards with different nursing organization: nurses’ ratings

AIMnThis paper is a report of a study to assess: (1) the relations between nursing organization models in hospital wards and nurses perception of the quality of patient care and dimensions of the practice environment, and (2) if these relations were modified by variations in local conditions at the ward level.nnnBACKGROUNDnPrevious literature is inconclusive concerning what model of nursing organization maximizes the quality of nursing services.nnnMETHODnA cross-sectional survey was carried out in a representative sample of Norwegian hospital wards in 2005. Intra-ward organization models were classified as: (1) Team leader (n = 30), characterized by extensive responsibilities for team leaders, (2) Primary nurse (n = 18), with extensive responsibilities for named nurses, and (3) Hybrid (n = 37), (1) and (2) combined. We prepared multilevel regression models using scales describing quality of patient care, learning climate, job satisfaction, and relationships with physicians as dependent variables. As independent variables, we used variables representing local ward conditions.nnnRESULTSnEighty-seven wards and 1137 nurses (55% response rate) provided complete data. The ward level proportion of variance ranged from 0.10 (job satisfaction) to 0.22 (relationships with physicians). The univariate effect of organization models on quality ratings was not statistically significant. Introducing local ward conditions led to a statistically significant effect of primary nurse organization on relationships with physicians, and to a substantial proportional reduction in ward level variance, ranging from 32% (quality of patient care) to 24% (learning climate).nnnCONCLUSIONnCaution is needed about using service quality arguments when considering the possible benefits and drawbacks of different organizational models.

A cross-sectional study to identify organisational processes associated with nurse-reported quality and patient safety

Objectives The purpose of this study was to identify organisational processes and structures that are associated with nurse-reported patient safety and quality of nursing. Design This is an observational cross-sectional study using survey methods. Setting Respondents from 31 Norwegian hospitals with more than 85 beds were included in the survey. Participants All registered nurses working in direct patient care in a position of 20% or more were invited to answer the survey. In this study, 3618 nurses from surgical and medical wards responded (response rate 58.9). Nurses practice environment was defined as organisational processes and measured by the Nursing Work Index Revised and items from Hospital Survey on Patient Safety Culture. Outcome measures Nurses assessments of patient safety, quality of nursing, confidence in how their patients manage after discharge and frequency of adverse events were used as outcome measures. Results Quality system, nurse–physician relation, patient safety management and staff adequacy were process measures associated with nurse-reported work-related and patient-related outcomes, but we found no associations with nurse participation, education and career and ward leadership. Most organisational structures were non-significant in the multilevel model except for nurses’ affiliations to medical department and hospital type. Conclusions Organisational structures may have minor impact on how nurses perceive work-related and patient-related outcomes, but the findings in this study indicate that there is a considerable potential to address organisational design in improvement of patient safety and quality of care.

An observational study: associations between nurse-reported hospital characteristics and estimated 30-day survival probabilities

Background There is a growing body of evidence for associations between the work environment and patient outcomes. A good work environment may maximise healthcare workers’ efforts to avoid failures and to facilitate quality care that is focused on patient safety. Several studies use nurse-reported quality measures, but it is uncertain whether these outcomes are correlated with clinical outcomes. The aim of this study was to determine the correlations between hospital-aggregated, nurse-assessed quality and safety, and estimated probabilities for 30-day survival in and out of hospital. Methods In a multicentre study involving almost all Norwegian hospitals with more than 85 beds (sample size=30, information about nurses’ perceptions of organisational characteristics were collected. Subscales from this survey were used to describe properties of the organisations: quality system, patient safety management, nurse–physician relationship, staffing adequacy, quality of nursing and patient safety. The average scores for these organisational characteristics were aggregated to hospital level, and merged with estimated probabilities for 30-day survival in and out of hospital (survival probabilities) from a national database. In this observational, ecological study, the relationships between the organisational characteristics (independent variables) and clinical outcomes (survival probabilities) were examined. Results Survival probabilities were correlated with nurse-assessed quality of nursing. Furthermore, the subjective perception of staffing adequacy was correlated with overall survival. Conclusions This study showed that perceived staffing adequacy and nurses’ assessments of quality of nursing were correlated with survival probabilities. It is suggested that the way nurses characterise the microsystems they belong to, also reflects the general performance of hospitals.