Rikard Lindqvist

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.

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.

Staffing and resource adequacy strongly related to RNs’ assessment of patient safety: a national study of RNs working in acute-care hospitals in Sweden

Introduction Although registered nurses (RNs) are central in patient care, we have not found prior research that specifically addresses how RNs assess the safety of patient care at their workplace and how factors in RNs’ work environment are related to their assessments. This study aims to address these issues. Methods 9236 RNs working with inpatient care in 79 acute-care hospitals in Sweden completed a national population-based survey, including Practice Environment Scale of the Nursing Work Index—Revised and items from Agency for Healthcare Research and Qualitys Hospital Survey on Patient Safety Culture. Correlation coefficients (Pearson and Spearman) and proportional odds regression were used for analysis. Results Nursing work environment factors were strongly related to RNs’ assessments of patient safety. RNs’ perception of having adequate staffing and resources improved their assessment of patient safety by at least two and a half times (OR 2.74 CI 2.52 to 2.97). RNs with a higher level of involvement in direct patient care gave a better patient safety grade than RNs with a more supervisory role. Most, but not all, patient safety culture items were related to RNs’ assessed patient safety grade. We found that work experience seemed to have no influence on RNs’ patient safety assessment. Conclusions While previous research emphasises patient-to-nurse ratios in strengthening patient safety practices, this study complements this by emphasising RNs’ own perception of having enough staff and resources to provide quality nursing care, as well as having good collegial nurse–physician relations and the presence of visible and competent nursing leadership—all factors highly related to RNs’ assessment of the safety of patient care at their workplace.

Structural characteristics of hospitals and nurse‐reported care quality, work environment, burnout and leaving intentions

AIM To investigate whether hospital characteristics not readily susceptible to change (i.e. hospital size, university status, and geographic location) are associated with specific self-reported nurse outcomes. BACKGROUND Research often focuses on factors within hospitals (e.g. work environment), which are susceptible to change, rather than on structural factors in their own right. However, numerous assumptions exist about the role of structural factors that may lead to a sense of pessimism and undermine efforts at constructive change. METHOD Data was derived from survey questions on assessments of work environment and satisfaction, intention to leave, quality of care and burnout (measured by the Maslach Burnout Inventory), from a population-based sample of 11 000 registered nurses in Sweden. Mixed model regressions were used for analysis. RESULT Registered nurses in small hospitals were slightly more likely to rank their working environment and quality of nursing care better than others. For example 23% of staff in small hospitals were very satisfied with the work environment compared with 20% in medium-sized hospitals and 21% in large hospitals. Registered nurses in urban areas, who intended to leave their job, were more likely to seek work in another hospital (38% vs. 32%). CONCLUSION While some structural factors were related to nurse-reported outcomes in this large sample, the associations were small or of questionable importance. IMPLICATIONS FOR NURSING MANAGEMENT The influence of structural factors such as hospital size on nurse-reported outcomes is small and unlikely to negate efforts to improve work environment.

Hospital organizational factors influence work-family conflict in registered nurses: Multilevel modeling of a nation-wide cross-sectional survey in Sweden.

BACKGROUND The present shortage of registered nurses (RNs) in many European countries is expected to continue and worsen, which poses a substantial threat to the maintenance of healthcare in this region. Work-family conflict is a known risk factor for turnover and sickness absence. OBJECTIVE This paper empirically examines whether the nurse practice environment is associated with experienced work-family conflict. DESIGN A multilevel model was fit with the individual RN at the 1st, and the hospital department at the 2nd level using cross-sectional RN survey data from the Swedish part of RN4CAST, an EU 7th framework project. The data analyzed here is based on a national sample of 8356 female and 592 male RNs from 369 hospital departments. RESULTS We found that 6% of the variability in work-family conflict experienced by RNs was at the department level. Organizational level factors significantly accounted for most of the variability at this level with two of the work practice environment factors examined, staffing adequacy and nurse involvement in hospital affairs, significantly related to work-family conflict. Due to the design of the study, factors on ward and work group levels could not be analyzed, but are likely to account for additional variance which in the present analysis appears to be on the individual level, with private life factors likely explaining another major part. CONCLUSION These results suggest that higher level organizational factors in health care have a significant impact on the risk of work-family conflict among RNs through their impact on the nurse practice environment. Lower level organizational factors should be investigated in future studies using hierarchical multilevel sampling.

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.

Intention to leave the workplace among nurses working with cancer patients in acute care hospitals in Sweden

PURPOSE To examine associations between perceived leadership and intention to leave the workplace due to job dissatisfaction among registered nurses (RNs) who care for patients with cancer. We also examine intention to leave in relation to proportion of cancer patients, length of time in practice, perceived adequacy of cancer care education, and burnout. METHODS AND SAMPLE The data originated from the Swedish component of RN4CAST, based on a survey of RNs working with in-patient care in all acute care hospitals in Sweden. The 7412 RNs reporting ≥10% patients with cancer on their unit were included in this analysis. Data were collected on perceptions of work environment, burnout, future employment intentions, and demographic characteristics. Additional questions related to cancer care. KEY RESULTS About 1/3 of all RNs intended to leave their workplace within the next year. Intention to leave was more prevalent among RNs reporting less favourable perceptions of leadership, who had worked ≤ two years as RN, who reported having inadequate cancer care education, and with higher burnout scores. Associations between leadership and intention to leave were stronger among RNs in the profession > two years, who reported having adequate cancer care education, and with lower burnout scores. CONCLUSIONS Perception of leadership is strongly associated with intention to leave among RNs in both specialized and general cancer care. This suggests a crucial area for improvement in order to reduce turnover rates.

Nurses’ practice environment and satisfaction with schedule flexibility is related to intention to leave due to dissatisfaction: A multi-country, multilevel study

BACKGROUND Nursing turnover is a major issue for health care managers, notably during the global nursing workforce shortage. Despite the often hierarchical structure of the data used in nursing studies, few studies have investigated the impact of the work environment on intention to leave using multilevel techniques. Also, differences between intentions to leave the current workplace or to leave the profession entirely have rarely been studied. OBJECTIVE The aim of the current study was to investigate how aspects of the nurse practice environment and satisfaction with work schedule flexibility measured at different organisational levels influenced the intention to leave the profession or the workplace due to dissatisfaction. DESIGN Multilevel models were fitted using survey data from the RN4CAST project, which has a multi-country, multilevel, cross-sectional design. The data analysed here are based on a sample of 23,076 registered nurses from 2020 units in 384 hospitals in 10 European countries (overall response rate: 59.4%). Four levels were available for analyses: country, hospital, unit, and individual registered nurse. Practice environment and satisfaction with schedule flexibility were aggregated and studied at the unit level. Gender, experience as registered nurse, full vs. part-time work, as well as individual deviance from unit mean in practice environment and satisfaction with work schedule flexibility, were included at the individual level. Both intention to leave the profession and the hospital due to dissatisfaction were studied. RESULTS Regarding intention to leave current workplace, there is variability at both country (6.9%) and unit (6.9%) level. However, for intention to leave the profession we found less variability at the country (4.6%) and unit level (3.9%). Intention to leave the workplace was strongly related to unit level variables. Additionally, individual characteristics and deviance from unit mean regarding practice environment and satisfaction with schedule flexibility were related to both outcomes. Major limitations of the study are its cross-sectional design and the fact that only turnover intention due to dissatisfaction was studied. CONCLUSIONS We conclude that measures aiming to improve the practice environment and schedule flexibility would be a promising approach towards increased retention of registered nurses in both their current workplaces and the nursing profession as a whole and thus a way to counteract the nursing shortage across European countries.