Luk Bruyneel

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.

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.

Effective strategies for nurse retention in acute hospitals: A mixed method study

BACKGROUND The realization of an organizational context that succeeds to retain nurses within their job is one of the most effective strategies of dealing with nursing shortages. OBJECTIVES First, to examine the impact of nursing practice environments, nurse staffing and nurse education on nurse reported intention to leave the hospital. Second, to provide understanding of which best practices in the organization of nursing care are being implemented to provide sound practice environments and to retain nurses. METHODS 3186 bedside nurses of 272 randomly selected nursing units in 56 Belgian acute hospitals were surveyed. A GEE logistic regression analysis was used to estimate the impact of organization of nursing care on nurse reported intention to leave controlling for differences in region (Walloon, Flanders, and Brussels), hospital characteristics (technology level, teaching status, and size) and nurse characteristics (experience, gender, and age). For the second objective, in-depth semi-structured interviews with the chief nursing officers of the three high and three low performing hospitals on reported intention to leave were held. RESULTS 29.5% of Belgian nurses have an intention-to-leave the hospital. Patient-to-nurse staffing ratios and nurse work environments are significantly (p<0.05) associated with intention-to-leave. Interviews with Chief Nurse Officers revealed that high performing hospitals showing low nurse retention were--in contrast to the low performing hospitals--characterized by a flat organization structure with a participative management style, structured education programs and career opportunities for nurses. CONCLUSION This study, together with the international body of evidence, suggests that investing in improved nursing work environments is a key strategy to retain nurses.

Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care

Objectives To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care. Design Cross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models. Setting Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland. Participants Survey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275 519 surgical patients in 188 of these hospitals. Main outcome measures Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction. Results Richer nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death. In our hospital sample, there were an average of six caregivers for every 25 patients, four of whom were professional nurses. Substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying. Conclusions A bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding nursing associates and other categories of assistive nursing personnel without professional nurse qualifications may contribute to preventable deaths, erode quality and safety of hospital care and contribute to hospital nurse shortages.

Organization of Hospital Nursing, Provision of Nursing Care, and Patient Experiences With Care in Europe

This study integrates previously isolated findings of nursing outcomes research into an explanatory framework in which care left undone and nurse education levels are of key importance. A moderated mediation analysis of survey data from 11,549 patients and 10,733 nurses in 217 hospitals in eight European countries shows that patient care experience is better in hospitals with better nurse staffing and a more favorable work environment in which less clinical care is left undone. Clinical care left undone is a mediator in this relationship. Clinical care is left undone less frequently in hospitals with better nurse staffing and more favorable nurse work environments, and in which nurses work less overtime and are more experienced. Higher proportions of nurses with a bachelor’s degree reduce the effect of worse nurse staffing on more clinical care left undone.

The Arabic version of the hospital survey on patient safety culture: a psychometric evaluation in a Palestinian sample

BackgroundA growing global interest in patient safety culture has increased the development of validated instruments to asses this phenomenon. The aim of this study is to investigate the psychometric properties of the Hospital Survey on Patient Safety Culture (HSOPSC) and its appropriateness for Arab hospitals.MethodsThe 7-step guideline of the Agency for Healthcare Research and Quality was used to translate and validate the HSOPSC. A panel of experts evaluated the face and content validity indexing of the Arabic version. Data were collected from 13 Palestinian hospitals including 2022 healthcare professionals who had direct or indirect interaction with patients, hospital supervisors, managers and administrators. Descriptive statistics and psychometric evaluation (a split-half validation technique) were then used to test and strengthen the validity and reliability of the instrument.ResultsWith respect to face and content validity, the CVI analysis showed excellent results for the Arab context (CVI = 0.96). As to construct validity, the 12 original dimensions could not be applied to the Palestinian data. Furthermore, three of the 12 original dimensions were not reliable (α <0.6). The split-half technique resulted in an optimal 11-factor model.ConclusionsOur study is the first study in the Arab world to provide an evaluation of the HSOPSC using Arabic data from Palestine. The Arabic translation of the HSOPSC comprises an 11-factor structure showing good validity and acceptable reliability. Despite the similarity between the Arab factor structure of the HSOPSC and that of the original one, and taking into account that our version may be applied in Arabic hospitals, there is a need for caution in comparing HSOPSC data between countries.

Work environment issues and intention-to-leave in Portuguese nurses: A cross-sectional study

This study extends the Registered Nurses Forecasting (RN4CAST) study evidence base with newly collected data from Portuguese nurses working in acute care hospitals, in which the measurement of the quality of work environment, workload and its association with intention-to-leave emerge as of key importance. Data included surveys of 2235 nurses in 144 nursing units in 31 hospitals via stratified random sampling. Multilevel multivariate regression analysis shows that intention-to-leave is higher among nurses with a specialty degree, nurses aged 35-39, and in nursing units where nurses are less satisfied with opportunities for career advancement, staffing levels and participation in hospital affairs. Analysis with moderation effects showed the observed effect of age and of having a specialty degree on intention-to-leave during the regression analysis is reduced in nursing units where nurses are more satisfied with opportunities for career advancement. The most important finding from the study suggests that promoting retention strategies that increase satisfaction with opportunities for career advancement among Portuguese nurses has the potential to override individual characteristics associated with increased turnover intentions.

Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study

Background Variation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery. Aim Examine if missed nursing care mediates the observed association between nurse staffing levels and mortality. Method Data from the RN4CAST study (2009–2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses’ staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation. Results Nurse staffing and missed nursing care were significantly associated with 30-day case-mix adjusted mortality. An increase in a nurse’s workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031–1.106) and 16% (OR 1.159 95% CI 1.039–1.294) increase in the odds of a patient dying within 30 days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality. Conclusion Missed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an ‘early warning’ indicator of higher risk for poor patient outcomes.