Saima Hinno The Professional Practice Environment Hospital Nurses´ Perspectives in Three European Countries Publications of the University of Eastern Finland Dissertations in Health Sciences SAIMA HINNO The Professional Practice Environment Hospital Nurses’ Perspectives in Three European Countries To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in Auditorium L1, Canthia building, University of Eastern Finland, on Friday, May 4th 2012, at 12 noon Publications of the University of Eastern Finland Dissertations in Health Sciences 107 Department of Nursing Science Faculty of Health Sciences University of Eastern Finland Kuopio 2012 Kopijyvä Oy Kuopio, 2012 Series Editors: Professor Veli-Matti Kosma, M.D., Ph.D. Institute of Clinical Medicine, Pathology Faculty of Health Sciences Professor Hannele Turunen, Ph.D. Department of Nursing Science Faculty of Health Sciences Professor Olli Gröhn, Ph.D. A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences Distributor: University of Eastern Finland Kuopio Campus Library P.O.Box 1627 FI-70211 Kuopio, Finland http://www.uef.fi/kirjasto ISBN (print): 978-952-61-0750-9 ISBN (pdf): 978-952-61-0751-6 ISSN (print): 1798-5706 ISSN (pdf): 1798-5714 ISSN-L: 1798-5706 III Author’s address: Department of Nursing Science Faculty of Health Sciences University of Eastern Finland KUOPIO FINLAND Supervisors: Professor Katri Vehviläinen-Julkunen, Ph.D. Department of Nursing Science Faculty of Health Sciences University of Eastern Finland Research Unit Kuopio University Hospital KUOPIO FINLAND Pirjo Partanen, Ph.D. Department of Nursing Science Faculty of Health Sciences University of Eastern Finland KUOPIO FINLAND Reviewers: Professor Sally Wai Chi Chan, Ph.D Alice Lee Centre for Nursing Studies Yong Loo Lin School of Medicine National University of Singapore SINGAPORE SINGAPORE Professor Walter Sermeus, Ph.D Centre for Health Services & Nursing Research Catholic University Leuven LEUVEN BELGIUM Opponent: Professor Elisabeth Severinsson, DrPH, RNT, RPN. Centre for Women’s, Family and Child Health Department of Nursing Science Faculty of Health Sciences Vestfold University College TØNSBERG NORWAY IV V Hinno, Saima The professional practice environment - hospital nurses’ perspectives in three European countries University of Eastern Finland, Faculty of Health Sciences, 2012 Publications of the University of Eastern Finland. Dissertations in Health Sciences 107. 2012. 48 p. ISBN (print): 978-952-61-0750-9 ISBN (pdf): 978-952-61-0751-6 ISSN (print): 1798-5706 ISSN (pdf): 1798-5714 ISSN-L: 1798-5706 ABSTRACT During recent years European countries have faced ongoing organizational changes in their health care systems. Successful organizational redesign initiatives seek to improve the quality care, health and institutional outcomes. Numerous studies have shown relationships between work environment, registered nurses’ (RNs’) job satisfaction and retention, as well as patient safety outcomes. Most of the studies that reflect these matters have been conducted in the USA and Canada. The purpose of this study was to examine RNs practice environment in hospital settings in Estonia, Finland and The Netherlands. Furthermore, to investigate the relationships between RN practice environment and nurse reported job and patient outcomes, as well as to assess the effects of various staffing patterns (nurse to patient ratios) on patient outcomes in Finnish and Dutch hospitals. Data were collected from RNs working in hospital settings in three European countries: Finland (n=535), The Netherlands (n=334) and Estonia (n=478). The original questionnaire used in this study for data collection in Finland and The Netherlands was initially developed in Finnish, and included the international Nursing Work Index – Revised (NWI-R) instrument. The Estonian data included covered only the statements of the NWI-R instrument together with background variables. In data analysis descriptive statistics, factor and regression analysis, t- and chi-square tests, analysis of variance and Kruskal-Wallis H test were used. The presence of supportive management was identified most frequently as an important RN practice environment characteristic across the datasets. In addition, teamwork, adequacy of resources and assurance of quality care were found to be significant and common across participating countries. Participants from Finland expressed more critical views towards their practice environment than their colleagues from The Netherlands and Estonia. Favourable evaluations of the adequacy of resources and supportiveness of management were positively correlated with nurse-assessed quality of care and job-related positive feelings. Shortcomings in resources and support referred to the negative correlations with job intentions. The incidence of patient adverse events were related to the staffing levels, and thus proved to be a nurse-sensitive patient outcome, irrespective of the country and the health care practices. This study has brought new evidence on the state of RN practice environment and its connection to several nurse- and patient outcomes. RNs’ evaluations of their practice environment identified both positive as well as challenging features of nurses’ everyday practice, specific to an individual country, and presented in European context comparison. Improving RNs’ professional practice environment is an essential national as well as international challenge that needs to be tackled, especially due to the nursing workforce shortage. Additional research on and continuous monitoring of RNs’ perceptions of their practice environment, including the adequacy of staffing levels, should be conducted systematically, and the gained information used, when making decisions affecting the nurses’ working environment at the hospital level, as well as in strategic level both nationally and internationally. Studies with longitudinal designs and alternative data collection methods and sources must be implemented. Medical Subject Headings (MeSH): Nursing Staff; Hospitals; Workplace; Organizational Culture; Job Satisfaction; Personnel Management; Quality of Health Care; Estonia; Finland; Netherlands National Library of Medicine Classification: WY 125 VI VII Hinno, Saima Hoitotyön toimintaympäristö sairaaloissa – sairaanhoitajien näkemyksiä kolmessa Euroopan maassa Itä-Suomen yliopisto, terveystieteiden tiedekunta, 2012 Publications of the University of Eastern Finland. Dissertations in Health Sciences 107. 2012. 48 s. ISBN (print): 978-952-61-0750-9 ISBN (pdf): 978-952-61-0751-6 ISSN (print): 1798-5706 ISSN (pdf): 1798-5714 ISSN-L: 1798-5706 TIIVISTELMÄ Terveydenhuollossa on ollut käynnissä laajoja organisatorisia muutoksia Euroopassa. Organisaatiouudistuksilla tavoitellaan korkeatasoista hoidon laatua, väestön terveyttä ja tuloksekasta toimintaa. Kansainväliset, erityisesti Yhdysvalloissa ja Kanadassa toteutetut tutkimukset ovat osoittaneet yhteyden hoitohenkilöstön työympäristön, työtyytyväisyyden ja alalle sitoutumisen, potilasturvallisuuden sekä hoitotulosten välillä. Tämän tutkimuksen tarkoituksena oli kuvata hoitotyön toimintaympäristöä Viron, Suomen ja Hollannin sairaaloissa sairaanhoitajien näkökulmasta. Lisäksi tutkimuksessa selvitettiin hoitotyön toimintaympäristön ja hoitotyön henkilöstön (potilas/sairaanhoitaja) ja potilastulosten välisiä yhteyksiä sekä arvioitiin henkilöstömitoituksen vaikutuksia potilastuloksiin Hollannissa ja Suomessa. Aineistot kerättiin sairaaloissa työskenteleviltä sairaanhoitajilta kolmessa Euroopan maassa: Suomessa (n=535), Hollannissa (n=334) ja Virossa (n=478). Suomen ja Hollannin aineisto kerättiin Suomessa kehitetyllä sairaanhoitajien työolobarometri mittarilla. Mittarin yksi osa-alue on magneettisairaalatutkimuksissa käytetty Nursing Work Index Revised (NWI-R) – mittaristo. Virossa aineisto kerättiin käyttämällä NWI-R mittaristoa, jossa kysyttiin lisäksi vastaajan taustatietoja. Aineiston analysoinnissa käytettiin faktori – ja regressioanalyysiä, khii neliötestiä, varianssianalyysiä sekä t-testiä ja Kruskal-Wallis H testiä. Sairaanhoitajat arvioivat johdon tuen tärkeäksi toimintaympäristön piirteeksi kaikissa kolmessa maassa. Lisäksi tiimityö, riittävät resurssit ja laadunvarmistus olivat merkittäviä toimintaympäristön tekijöitä. Suomalaiset sairaanhoitajat arvioivat toimintaympäristöään hollantilaisia ja virolaisia sairaanhoitajia kriittisemmin. Henkilöstövoimavarojen riittävyys ja johdon tuki korreloivat positiivisesti hoitajien arvioimaan hoidon laatuun ja työhön liittyviin positiivisiin tunteisiin. Sairaanhoitajien arviot riittämättömästä henkilöstömitoituksesta olivat yhteydessä heidän ajatuksiinsa vaihtaa ammattiuraa (työyksikköä, organisaatiota tai ammattia). Myös sairaanhoitajien saama johdon tuki selitti vaihtoaikeita. Tulokset osoittivat, että potilasmäärä sairaanhoitajaa kohden korreloi suoraan potilaille sattuneiden haittatapahtumien kanssa Hollannissa ja Suomessa. Tämä tutkimus on tuottanut uutta tietoa Eurooppalaisten sairaanhoitajien ammatillisesta toimintaympäristöstä ja sen yhteydestä henkilöstön ja potilaiden tuloksiin. Tulokset kuvaavat hoitotyön toimintaympäristön kehittämisen haasteita yksittäisissä maissa ja kansainvälisesti vertaillen. Sairaanhoitajien toimintaympäristöön ja siihen liittyviin tekijöihin tulee kiinnittää huomiota entistä enemmän alan kasvavan työvoimatarpeen vuoksi. Sairaanhoitajien toimintaympäristön tutkimusta tarvitaan ja tätä jatkuvaa arviointitietoa tulisi hyödyntää henkilöstövoimavarojen suunnitteluun liittyvässä päätöksenteossa. Aihetta on tärkeä tutkia pitkittäistutkimuksella, hyödyntäen vaihtoehtoisia tiedonkeruun menetelmiä ja lähteitä. Yleinen Suomalainen asiasanasto: hoitohenkilöstö; sairaalat; työympäristö, henkilöstöresurssit; henkilöstöjohtaminen; hoitotulokset, Alankomaat; Suomi; Viro Luokitus: WY 125 työhyvinvointi; VIII IX Acknowledgements There have been many people who supported and encouraged me through the journey of my doctoral studies and completion of this dissertation. I am grateful to all of them. Some of them I would like to mention particularly. I would like to express my deep and sincere gratitude to my main supervisor professor Katri Vehviläinen-Julkunen (PhD). Her understanding, encouraging and personal guidance have provided a good basis for the present thesis. I am deeply grateful to my supervisor Pirjo Partanen (PhD), for her constructive comments, encouraging support and guidance throughout this work. My sincere thanks are due to the official reviewers, professor Sally Wai Chi Chan (PhD) and professor Walter Sermeus (PhD), for their valuable and constructive comments which helped me to improve the manuscript. Many people were involved with collecting data, for which I would like to thank them wholeheartedly. I would like to thank all nurses participating in this study either directly (in The Netherlands, NU’91 members), or via other projects like in Finland (Finnish Nurses Association membership survey) and in Estonia (PRAXIS in collaboration with Estonian Nurses Union). I owe my deep gratitude to the Finnish Nurses Association and in particular Katriina Laaksonen (MSc) for providing the permissions to use and translate the questionnaire; to NU’91 board for their permission to reach participants via their membership database and for their collaboration, and Aaldert Mellema coordinating the data collection at NU’91. I also owe my sincere gratitude and appreciation to Estonian Centre for Policy Studies (PRAXIS) and particularly to Ain Aaviksoo (MD, MPH) for the research collaboration and enabling me generously access to the data gathered in Estonia. I wish to thank Marja-Leena Hannila (MSc) for her advice and support in statistical analyses and reporting the results. I am grateful to the whole staff of the Department of Nursing Science at the University of Eastern Finland, and particularly Katja Immonen (MSc) for her assistance concerning the final version of this thesis; Leena Halonen for her assistance in many practical matters. I want to express my sincere thanks to Maija Pellikka – for her generous support and assistance throughout the years. Under her supervision I baked my first kalakukko. I appreciate the time we spent together. It was a pleasure to share the ideas and dreams together with the doctoral students from the “researchers-room” through the years spent in Kuopio. Specially, many thanks to Linda Hong-Gu He (PhD), Maria Psychogiou (MSc) and Marjorita Sormunen (MSc) for your friendship. I also owe my thanks to Tarja Tervo-Heikkinen (PhD) - our common research interest has brought us together. I appreciate the insightful discussions and your support. I wish to thank Evanthia Sakellari (MSc) for your friendship and encouraging discussions. I would like to thank the staff of the Department of Nursing Science at the University of Tartu, Estonia for the opportunity to share my knowledge with them and to learn from them while being a lecturer, a member of various committees, counseling and supervising their students. I owe my sincere thanks to Pirjo Kinnunen (PhD) and her family. I appreciate very much your friendship. I am very happy about the fortune I had to join The European Academy of Nursing Science. It opened the way to a broad network of international nurse-researchers. I would like to express my sincere gratitude and appreciation to Anna Huizing (PhD), Monique Du Moulin (PhD) and Susan Broekmans (PhD) for generously helping me through the translation process. I also want the express my gratitude to professor Koen Milisen (PhD) from the Catholic University of Leuven, Belgium for his support by providing me the translated version of NWI-R used in Belgium in the early stage of this study process. I owe my deepest gratitude to Teija Korhonen (PhD) being a great friend and being always there for me - your faithful support throughout all the years is so appreciated. X I am most grateful to my parents who encouraged me to reach for my goals and their support has been incredible. Südamlikud tänud Teile, kallid vanemad! Above all I owe my loving gratitude to my family. The support from my husband has been indispensable. As he holds a PhD himself, he knew exactly what I was going through. Our wonderful sons have brought sunshine to every day. They have made great efforts to help me since their first drawings ever appeared on the back side of the draft version of my articles. During the development of this dissertation I received financial support from EVO funding at Northern-Savo Hospital District, Kuopio University Hospital, the Finnish Association of Nursing Research (HTTS ry), Saastamoisen Foundation (Saastamoisen Säätiö) at Kuopio University Foundation, Estonian World Council, Inc. (Margot M. and Herbert R. Linna scholarship) (Gaithersburg, USA), Finnish Post-Graduate School in Nursing Science and the Finnish Foundation for Nursing Education via the Helmi-project (National Nurse Staffing Measurement project at the Department of Nursing Science, University of Kuopio and University of Eastern Finland). I owe my deep gratitude to all of them for their support. Lelystad April, 2012 Saima Hinno XI List of the original publications This dissertation is based on the following original publications: I Hinno S, Partanen P, Vehviläinen-Julkunen K, Aaviksoo A. Nurses' perceptions of the organizational attributes of their practice environment in acute care hospitals. Journal of Nursing Management 17: 965-74, 2009. II Hinno S., Partanen P. and Vehviläinen-Julkunen K. Hospital nurses' work environment, quality of care provided and career plans. International Nursing Review, 58: 255–262, 2011. III Hinno S., Partanen P. and Vehviläinen-Julkunen K. The professional nursing practice environment and nurse – reported job outcomes in two European countries: A survey of nurses in Finland and The Netherlands. Scandinavian Journal of Caring Sciences, 26: 133-143, 2012. IV Hinno S., Partanen P. and Vehviläinen-Julkunen K. Nursing activities, nurse staffing and adverse patient outcomes as perceived by hospital nurses. Journal of Clinical Nursing. In press. The publications are reprinted with the kind permission of the copyright holders. Summary also includes previously unpublished material. XII XIII Contents 1 INTRODUCTION ........................................................................................................................ 1 2 THE PROFESSIONAL PRACTICE ENVIRONMENT AND NURSING OUTCOMES . 3 2.1 The nursing practice environment ........................................................................................ 3 2.2 The professional practice environment in relation to nurse and patient outcomes ....... 4 2.2.1 Linking the professional practice environment and nurse-reported job outcomes ..................................................................................................................... 5 2.3 Measurement of professional practice environment .......................................................... 8 2.3.1 Instruments ....................................................................................................................... 8 2.3.2 Revised Nursing Work Index ..................................................................................... 10 2.4 Country profiles of the three countries ............................................................................... 16 2.4.1 Overview of the health care systems .......................................................................... 17 2.4.2 Nursing workforce profiles .......................................................................................... 18 2.5 Summary of the theoretical basis of the study ................................................................... 20 3 PURPOSE OF THE STUDY ..................................................................................................... 21 4 METHODS ................................................................................................................................... 22 4.1 Design ..................................................................................................................................... 22 4.2 Sample, setting and data collections.................................................................................... 23 4.3 Validity and reliability of the instrument ........................................................................... 23 4.3.1 Instrument translation process .................................................................................... 24 4.4 Data analysis ........................................................................................................................... 25 4.5 Ethics of the study .................................................................................................................. 25 5 RESULTS ...................................................................................................................................... 26 5.1 Demographic, employment and nurse staffing characteristics ....................................... 26 5.2 Hospital nurses’ practice environment ............................................................................... 28 5.3 Relationships between the nurse practice environment and job outcomes................... 32 5.4 Nursing activities, RN to patient ratios as nurse staffing indicators and adverse patient outcomes .................................................................................................................... 32 5.4.1 Distribution of RNs’ daily activities in hospital settings ......................................... 32 5.4.2 Nursing activities and relationships with the patient to RN ratio ......................... 33 5.4.3 Patient to RN ratios and adverse patient outcomes ................................................. 33 5.5 Summary of the main results................................................................................................ 34 6 DISCUSSION .............................................................................................................................. 35 6.1 Reflection on the crucial findings and their significance.................................................. 35 6.1.1 The professional practice environment ...................................................................... 35 6.1.2 Practice environment in relation to nurse-reported outcomes ............................... 36 XIV 6.1.3 Nurse staffing and patient outcomes ........................................................................ 37 6.2 Reflection on validity and reliability ................................................................................... 37 6.2.1 The NWI-R instrument ................................................................................................. 37 6.2.2 The sample...................................................................................................................... 38 6.2.3 Data analysis and results .............................................................................................. 38 6.2.4 Generalizability of the results ..................................................................................... 38 6.3 Strengths and weaknesses .................................................................................................... 38 6.4 Implications............................................................................................................................. 39 6.5 Recommendations for further research .............................................................................. 40 7 CONCLUSIONS ......................................................................................................................... 41 REFERENCES ............................................................................................................................... 42 APPENDIX: Original publications XV Abbreviations AGFI Adjusted Goodness of Fit Index AWES Assessment of Work Environment Schedule EC European Commission EOM Essentials of Magnetism EU European Union EUROSTAT Statistical Office of the European Union GDP Gross Domestic Product HEALTH PROMeTHEUS Health Professional Mobility in the European Union HCB Health Care Board HELMI-project Staffing Measurement project LPN Licensed Practical Nurse MoHProf Mobility of Health Professionals NEXT The Nurses’ Early Exit NU’91 Nieuwe Unie’91 NWI Nursing Work Index NWI-EO Nursing Work Index - Extended Organisation NWI-R Nursing Work Index Revised NWI-RVL Nursing Work Index – Revised in Flemish OECD Organisation for Economic Cooperation and Development OR Odds Ratio PEI Practice environment index PES-NWI Practice Environment Scale of the Nursing Work Index PNWE Perceived Nursing Work Environment instrument PPE scale Professional Practice Environment Scale. PRAXIS Estonian Centre for Policy Studies RMSEA Root Mean Square Error of Approximation RN Registered Nurse RN4CAST Nurse Forecasting SD Standard Deviation SEM Structural Equation Modeling XVI WES Work Environment Scale WHO World Health Organization WOFS Ward Organization Features Scale WQI Work Quality Index 1 Introduction The practice environment experienced by nurses has received increasing attention in the international arena because of the restructuring and reorganization of health care services in many countries during the last decade. These actions have highlighted two central issues in every country’s health care system: nursing shortages and patient safety (Aiken et al. 2008, van Bogaert et al 2010, Gormely 2011, Institute of Medicine 2010, Lake 2007, Schalk et al. 2010, Sermeus et al. 2011). The overall goal of every hospital or healthcare organization is, systematically, to develop and reinforce organizational strategies, structures, and processes that improve the organization’s effectiveness, particularly in achieving quality patient care and employee job satisfaction (Solomons & Spross 2011, Kramer & Schmalenberg 2008). An excellent nursing organization, which can sustain and ensure high quality care, requires nurses to deliver a high level of performance in nursing teams supported by appropriate hospital management policies and good collaboration with physicians. It has been recommended that hospital units should have a transparent vision with clear goals and strategies for staff nurses with accustomed and accurate management approach in order to cope with the health care issues in acute care hospitals now and in the future (Aiken et al. 2008, Buchan & Aiken 2008, van Bogaert et al. 2010). Policy makers and hospital administrators seek evidence to support nurse staffing decisions that includes both the volume and mix of nurses required to provide efficient and effective care (O’Brien-Pallas et al. 2004). Furthermore, understanding what nurses perceive as important aspects of the work environment, and targeting strategies to improve these characteristics are essential in the retention of nurses, and in determining quality of care delivery (Gormely 2011, Lin & Liang 2007). There is evidence that the professional practice environment of nurses comprises multiple characteristics and therefore cannot be measured by one single outcome measure (Schalk et al. 2010). Duffield and colleagues (2010) state that research in this field has reached the point at which systematic reviews and other studies of the relationships between various combinations of nurse staffing (e.g. number and skill mix), workload, work environment and patient outcomes are being undertaken. Previous research has consistently demonstrated that nurse staffing variables are important predictors of outcomes (e.g. Needleman et al. 2002, Choi et al. 2004, Rafferty et al. 2007, Kramer & Schmalenberg 2008, Lin & Liang 2007, van Bogaert et al. 2010). Several studies have described associations between nurses’ perceptions of their practice environment and nurse outcomes such as burnout, job satisfaction, turnover, intention to leave, and nurse reports of the quality of care, as well as patient outcomes such as mortality and failure to rescue (Aiken et al. 2008, Estabrooks et al. 2005, Friese et al. 2008, Kramer & Schmalenberg 2008, Laschinger & Leiter 2006, van Bogaert et al.2009a, 2009b). The practice environment of nurses has been described in the literature, and by nurses themselves, as chaotic, stressful and fast-paced (O’Brien-Pallas et al. 2006, Schalk et al. 2010). Although many countries are experiencing a crisis in nursing due to the high nursing shortages and subsequent deterioration of work and there is consensus that improvement of nurses’ practice environment is crucial (O’Brien-Pallas et al. 2006), the research evidence concerning the current situation in European countries is inconclusive. Albeit, there are few European wide studies conducted aiming to provide evidence needed for meeting the challenge of developing and retaining an adequate health workforce in European countries. The Nurses’ Early Exit Study (NEXT) was a major survey conducted in 10 European countries (Belgium, Finland, France, Germany, Great Britain, Italy, the Netherlands, Poland, Sweden, Slovakia) that explored nurses’ working 2 conditions and the variables associated with retention in 2002-2005 (Hasselhorn et al. 2005). Another Europe-wide project, currently in progress (2009-2011), is the Nurse Forecasting, RN4CAST, project. There are 12 European countries participating (Belgium, Finland, Germany, Greece, Ireland, Norway, Poland, Spain, Sweden, Switzerland, The Netherlands and England). The objective of this project is to refine current forecasting models for planning the nursing workforce, using new elements such as perception of various aspects of the nursing work environment and the impact of nurse deployment on recruitment, retention and productivity of nurses and on patient outcomes (Sermeus et al. 2011, Bruyneel et al. 2009). In addition, there are two other large scale research projects undergoing, namely Mobility of Health Professionals (MoHProf) and Health Professional Mobility in the European Union Study (HEALTH PROMeTHEUS). Their ultimate aim is to provide a significant contribution to future thinking on the movement of health professionals in the European Union. Thus, the importance of workforce issues, including those relating to nurses, has received already attention on a political level in the European Union. The present study involves three European countries: Finland, Estonia and The Netherlands. Selection of these three countries was influenced by a variety of factors. First, the challenges that nurses face are very similar across countries despite differences in resources and national health care system designs (Aiken et al. 2008, van Bogaert et al.2009a). Previous research has referred to the shortcomings associated with nurses’ work environment as core problems in work design and workforce management, thus threatening the provision of care. Second, all three participating countries are members of the European Union, with different lengths of membership, and they have recently experienced changes in their respective health care systems. Furthermore, of all the health care systems of the European union, the researcher herself was most familiar with these three. The themes of similarity and difference within Europe create a unique opportunity to study nursing workforce issues while learning common lessons across countries (Sermeus et al. 2011). This study was initiated to examine Estonian, Finnish and Dutch hospital nurses’ work environment in relation to nurse staffing, and nurse-reported job and patient outcomes. The current study also covers information regarding the variety of RNs’ daily tasks. Many studies of the relationship between nurse staffing and outcomes lack a micro-level theory of how nurses create quality of care, a fact that has been criticised in the past (e.g. Mark and Harless 2011). The current work addresses this problem. Such baseline information is needed to discover what it is that nurses do, and how they do it, in order to ensure quality and safe patient care in their daily practice. Furthermore, establishing baseline confirmation of the state of the work environment according to staff nurses is a necessary first step towards achieving the next objective of improving nurses’ work environment so that the goals of improved quality of care for patients, increased job satisfaction for nurses and retention of nurses can be achieved (Kramer & Schmalenberg 2008, Kramer et al. 2011). This thesis consists of this summary and four original contributions, papers published in scientific peer-reviewed nursing journals. The summary part provides an overarching theoretical background for the original contributions. The aims of the present study were to provide international perspectives on issues associated with the professional practice environment, as perceived by registered nurses in hospital settings, and to produce knowledge to provide the evidence needed to develop future nursing workforce strategies to enhance the performance of hospitals and health systems. Therefore, the purpose of this study was to examine RNs’ practice environment in hospital settings in Estonia, Finland and The Netherlands. Furthermore, the intention was to investigate the relationships between practice environment and nurse-reported job and patient outcomes, as well as to assess the effects of various staffing patterns on patient outcomes in Finnish and Dutch hospitals. 3 2 The professional practice environment and nursing outcomes 2.1 THE NURSING PRACTICE ENVIRONMENT A professional practice environment can be described as the system that supports nurses’ control over the delivery of nursing care, the environment in which care is delivered and the characteristics of an organization that facilitate or constrain professional nursing practice (Aiken & Patrician 2000, Lake 2002). Although the impact of the work environment on professional practice has been described extensively in the nursing literature during the last decade, it is important to note that previous literature also provides evidence of the professional nursing practice environment being approached from slightly different perspectives different times. Lake (2007) refers to clear phases in the research priorities. In the 1980s, the practice environment was explored with the purpose of gaining a better understanding and influencing nurses’ job satisfaction and turnover. In the following decade, the 1990s, attention shifted to explaining the quality of care and patient outcomes. Recently, the focus has turned to relationships between the practice environment and patient safety (Institute of Medicine 2004, Kim et al. 2011, van Bogaert et al. 2009b). The nursing practice environment is a complex and multidimensional construct, comprising numerous components and relationships between them. Initial research on magnet hospitals by Kramer and Hafner (Aiken et al. 2001, 2002) provided empirical evidence regarding organizational characteristics that facilitated professional nursing practice. Currently, to define the nursing practice environment, several researchers are using a set of related concepts, which are described as organizational characteristics influencing nursing practice and known as the ‘forces of magnetism’ (e.g. Aiken and Patrician 2000, Erickson et al. 2004, Sleutel 2000, Wolf & Greenhouse 2006). These characteristics are as follows: autonomy, control over one’s practice, status and value of nursing, collaborative governance, professional staff leadership, interdisciplinary communication and teamwork; enhanced internal work motivation, a philosophy of clinical care emphasizing quality, professional development opportunities, supportive management, reasonable workload, flexible scheduling, organizational polices and innovations, workplace safety and delivery of culturally sensitive, competent care to patients of all ethnic groups (Arford & Zone-Smith 2005, Lake 2007, McGillis Hall et al. 2003, Milisen et al. 2006, Wolf & Greenhouse 2006, van Bogaert et al. 2009b). The characteristics listed above have been used in several ways in previous research. Mostly they have been identified in order to develop practice environment scales (Aiken and Patrician 2000, Erickson et al. 2004), prioritize and/or address nursing work-life concerns, develop a framework of nursing work-life or healthy work environments, act as hallmarks or critical factors for assessing a professional nursing practice environment and for achieving work environment excellence (American Association of Colleges of Nursing 2008). Moreover, they have been regarded as essential attributes for quality care, or used to create a program for staff nurses to improve the working environment (Schalk et al. 2010). By treating the nurse practice environment as a complex system, approaches can result in greater nurse professionalism, empowerment and patient safety (Laschinger et al. 2001, 2003, Lin & Liang 2007). A professional practice environment supports nurses’ ability to function at the highest level of clinical practice, to work effectively in an interdisciplinary team of caregivers, and to mobilize resources quickly (Lake 2007). 4 2.2 THE PROFESSIONAL PRACTICE ENVIRONMENT IN RELATION TO NURSE AND PATIENT OUTCOMES Numerous studies have found relationships between the professional practice environment and registered nurses’ job satisfaction and retention (Gardulf et al. 2008, McGillis Hall et al. 2003, Arford & Zone-Smith 2005, Wolf & Greenhouse 2006). Nurse outcomes are often reported as indicators of organizational outcomes (Mark et al. 2003). Cummings and colleagues (2010) presented three dimensions that provide broad and comprehensive perspectives for reviewing nurse outcomes. The first is satisfaction with their work, role and pay. This category covers nurse satisfaction with job mobility options, job security, financial reward and time available to spend with patients. The second dimension is nurses’ relationship with work. This category covers nurse intent to stay or leave (current unit, organization or profession), actual turnover, absenteeism and retention. The third category includes nurses’ health and well-being. Such indicators include general health complaints, stress, anxiety, emotional exhaustion and job tension. All these dimensions are closely related, and one may influence another. In addition, the measures used to assess nurse outcomes tend also to identify adverse outcomes. Adverse outcomes reflect work-related accidents, such as sharp-device injuries (Clarke 2007, Tervo-Heikkinen et al. 2008), slipping, injuries caused by lifting or moving patients and injuries caused directly by patients (Tervo-Heikkinen et al. 2008). A large multinational European study on early departure from the nursing profession reported a connection between the organizational environment and adverse nurse job outcomes such as burnout, poor work ability and intent to leave nursing (Hasselhorn et al. 2005). There is reported evidence about the relationships between practice environment factors and nurse occupational injuries with used sharps and needle-sticks (Clarke 2007). Van Bogaert and colleagues (2009b) studied the relationship between nurses’ work environment and job outcomes (e.g. job satisfaction, burnout and turnover) as well as nurse-assessed quality of care. A professional nursing practice environment characterized by high quality leadership and management, sufficient staffing, positive nurse-physician relationships, reasonable workloads and appropriate working conditions is required to ensure and sustain high quality patient care (Solomons & Spross 2011, Milisen et al. 2006). Van Bogaert and colleagues (2009b) suggest that such conditions appear to reduce nurse burnout and improve nurse job satisfaction and intention to stay both in the hospital and in the nursing profession. Moreover, poor organizational environments at different levels appear to lead to feelings of exhaustion, cynicism and inefficacy, which in turn reduce job satisfaction, increase risks of departure from the organization or nursing practice and have potentially negative impacts on quality of care. In contrast, organizational and managerial support for positive work environments appears to attract and retain professional nurses and provide a foundation for high quality nursing care (van Bogaert et al. 2009b). Nurses commonly express increasing concern about their ability to deliver quality care as a result of reductions in staffing levels, an inappropriate skill mix and altered organisational design (Bleich et al. 2003, Capuano et al. 2004, Currie et al. 2005, McGillis Hall 2005, Welton 2007). Viewed through a patient safety lens, work environments have the potential to prevent and mitigate errors inherent in human operations and activities. Thus, the patient safety movement has further raised awareness of the importance of a systems approach, as opposed to an exclusive focus on individual factors when studying errors (van Bogaert et al. 2010). Patient outcomes that are sensitive to nursing care include both quality-related outcomes (e.g. patient satisfaction, ability to perform self-care activities on discharge from hospital) (Pringle & Doran 2003) and patient safety (also known as risk-related) outcomes (e.g. falls, infections, pressure ulcer/decubitus, complications, medication errors, mortality) (Doran et al. 2006). Researchers in several countries stress that increased nursing hours and a richer skill mix (more RNs) improve patient outcomes (Aiken et al. 2008, Duffield et 5 al. 2010, Kane et al. 2007, Lin & Liang 2007). Hospitals with more favourable nurse-topatient ratios have been found to have lower mortality rates and lower failure to rescue rates (Aiken et al. 2010, Estabrooks et al. 2005). Nurse staffing is closely linked to patient outcomes and system effectiveness (Aiken et al. 2002, Bae 2011, Cho et al. 2009, Currie et al. 2005, Gunnarsdottir et al. 2009, Kane et al. 2007, Laschinger et al. 2001, Laschinger & Leiter 2006, O’Brien-Pallas et al. 2004, Tervo-Heikkinen et al. 2008). A lower proportion of RNs in the nursing workforce is associated with increased patient length of stay, incidence of hospital acquired infections, prevalence of pressure ulcers, urinary tract infections, pneumonia, shock and cardiac arrest, upper gastrointestinal bleeding (Dall et al. 2009, Currie et al. 2005) and higher rates of medication errors and hospital acquired infections (McGillis Hall et al. 2008). It is also known that, when there is a shortage of RNs, nurse positions are filled by less qualified nurses (Buchan & Aiken 2008). To counter such practices, research has provided evidence that nurses' education makes a difference to patient outcomes. Hospitals with a larger proportion of staff nurses with bachelor's or higher degrees have reported significantly lower mortality rates (Aiken et al. 2003, Estabrooks et al. 2005). Adequate resources (covering staffing issues) are often listed among the magnet characteristics of a professional practice environment (American Nurses Association 2004, American Nurses Credentialing Center 2005). Inadequate staffing and unrealistic workloads place an unnecessary burden on nursing staff, reduce the quality of care that nurses are able to provide, and lead to fatigue, unachievable expectations and uncompleted tasks (Garrett 2008), burnout and job dissatisfaction (Aiken et al. 2002, Cho et al. 2009, Rafferty et al. 2007, van Bogaert et al. 2009b). Moreover, nurses’ needle-stick injuries are also related to unfavourable staffing levels (Clarke 2007). Although there is increasing evidence from research that a higher number of RNs is associated with better patient safety, it has been suggested that nurse staffing and the practice environment together influence patient outcomes both directly and indirectly through nurse job outcomes (Laschinger & Leiter 2006, Lake 2007). Outcome related data can be retrieved from hospital databases or gathered directly from nurses via surveys. Nurse outcomes of interest in the current study context were captured by using the concept of nurse-reported job outcomes. This approach provided an indication of nurses’ reactions to their work (such as job-related feelings and job intentions) on the one hand, and work-related outcomes resulting from the nursing work process (such as adverse events affecting both nurses and patients) and the quality of patient care provided, on the other hand. 2.2.1 Linking the professional practice environment and nurse-reported job outcomes As illustrated above, there is a growing body of research evidence linking the nurse practice environment to outcomes. In general, combined methods involving nurse surveys and administrative databases, are used to investigate the phenomena. It is noteworthy that there are relatively few studies considering the link from the nurses’ perspectives and using a nurse–reported approach. The small number of such studies including nurseassessed patient outcomes may be explained by a desire to avoid bias. The literature review described here focused on papers that identified relationships between nurses’ practice environment and nurse-reported job and patient outcomes. If available in the papers, nurse staffing measures were also reported. The papers being identified during this search covered the time period from 1997 to 2010. While most studies on the subject discussed above originated from the USA and Canada, the current review, covering only studies addressing nurse – reported outcomes, identified data from a variety of countries, including Belgium, Finland, Germany, Japan, Korea, Switzerland, and the USA (Table 1). The review was based on searches of the electronic databases PubMed and Cinahl for the keywords: practice environment, hospital, nurse–assessed outcome, nurse outcome, patient outcome. The computer search was accompanied by manual searching of journals 6 and reference lists from the articles identified. The criteria for including papers were that the study must have been published in a scientific journal and only studies in which nurse-assessed outcomes were reported were included. Staffing indicators were not available in all studies included in the review. Table 1 Studies (n=14) from 1997-2010 about the nursing practice environment, including nurse-reported job and patient outcomes. Author(s), year, country of data collected Practice environment indicators /instrument Staffing indicator Nurse reported job outcome Nurse reported patient outcomes Aiken et al. 2008 US Nursing Work IndexRevised (NWI-R) n/a Job satisfaction, burnout, intention to leave, Quality of care Baernholdt & Mark 2009 US decentralization, autonomy, relational coordination Proportion of RNs, vacancy rate, experience, education, expertise, commitment to care Job satisfaction, turnover n/a van Bogaert et al. 2009a, b, 2010, Belgium Revised Nursing Work Index developed for research in the Dutch-speaking part of Belgium (NWI-R) n/a Job satisfaction, burnout, intention to leave Quality of care Bruyneel et al. 2009, Belgium NWI-R-VL n/a Job satisfaction, burnout n/a Chen & Johantgen 2010, Germany, Belgium Magnet Hospital attributes: Quality of nursing leadership, n/a Job satisfaction n/a the number of patients per nurse measured at the unit level, perception of staffing adequacy at the nurse level Job dissatisfaction, burnout, intention to leave Quality of care Management style, Personnel policies, Autonomy, Interdisciplinary relationships, Professional development Cho et al. 2009, Korea nurse questionnaire Table 1 continues 7 Table 1 continued Author(s), year, country of data collected Practice environment indicators /instrument Staffing indicator Nurse reported job outcome Nurse reported patient outcomes Kanai-Pak et al. 2008, Japan NWI-R n/a Job satisfaction, burnout Quality of care Manojlovich & DeCicco, 2007 Practice Environment Scale of the Revised Nursing Work Index (PES – NWI-R) n/a n/a Ventilatorassociated pneumonia (frequency), medication errors (frequency), catheterassociated sepsis (frequency) Schubert et al. 2007, 2008, Switzerland NWI-R Patient-to-nurse staffing ratio Job satisfaction Quality of care, medication errors, patient falls, nosocomial infections, pressure ulcers, critical incidents involving patients Tervo-Heikkinen et al.2008, Finland NWI-R Proportion of each ward’s total RN hours during first quarter of 2005 Job satisfaction, stress, adverse events affecting nurses (e.g. sharp-device injuries, slipping, injuries caused by patients, injuries caused by lifting or moving patients) Medication errors, nosocomial infections, pressure ulcers Vahey et al 2004, USA NWI-R Unit staffing and skill mix Burnout, intention to leave Patient falls n/a – information not-available Most frequently the nurse job outcome, reported as the nurse-assessed outcome variable, was job satisfaction, followed by burnout (measured mostly by the Maslach Burnout Inventory Index) and intention to leave. With respect to nurse-reported patient outcomes, overwhelmingly, nurses' perceptions of patient care quality were the measures used. Other patient outcome related variables also appear a number of times in the literature (Table 1). 8 2.3 MEASUREMENT OF PROFESSIONAL PRACTICE ENVIRONMENT 2.3.1 Instruments To study the phenomena associated with a professional nursing practice environment, multidimensional instruments need to be used. Such instruments can be expected to identify shortcomings in the current practice environment and thus, be useful when planning improvements. To investigate, which instruments have been used to study nurses’ perceptions of their practice environment an additional literature search was performed. Research studies were identified for this review by searching PubMed and Cinahl for articles referencing professional nursing practice environment measurement(s). In addition, a manual search of reference lists from the articles identified was performed. The key-words used were as follows: nurse, practice environment, tool/instrument/questionnaire, hospital. The papers identified by this search procedure represented the period from 1989 to 2011. The criterion for including an article was that the study must have been published in a nursing peerreviewed journal. As a result, the 13 instruments listed in Table 2 were identified. The NWI-R and PES-NWI instruments are widely used to measure the nurse practice environment in nursing research internationally (Lake 2002, Lake and Friese 2006, Upenieks 2002, Budge et al. 2003). Nevertheless, the NWI-R has been used more extensively in European countries (e.g. in Belgium, Finland, Iceland, Ireland). Despite the variety of instruments used to measure practice environments, many of the items included in them can be traced back to the theoretical literature describing professions and the empirical literature describing magnet hospitals. 9 Table 2 Instruments used in previous studies to evaluate the professional practice environment Instrument: name and abbreviation (if known) Author(s) Field in which the named instrument was developed (1) Nursing Work Index (NWI) Kramer and Hafner 1989 Nursing research (2) Revised Nursing Work Index (NWI-R) Aiken and Patrician 2000 Nursing research (3) Practice Environment Scale of the Nursing Work Index (PES-NWI) Lake 2002 Nursing research (4) Perceived Nursing Work Environment instrument (PNWE) Choi et al. 2004 Developed in nursing research and derived from the NWI-R item pool (5) Practice environment index (PEI) Estabrooks et al. 2002 Developed in nursing research and derived from the NWI-R item pool (6) Professional Practice Environment (PPE) Scale. Erickson et al. 2004 Developed in nursing research and derived from the NWI-R item pool (7) NWI-RVL – previously translated and validated NWI-R developed for research in the Dutch-speaking part of Belgium van Bogaert et al.2009a Developed in nursing research and derived from the NWI-R item pool (8) NWI-Extended Organisation (NWIEO) – to evaluate individual perceived psycho-social and organizational work factors (POWF) levels in order to focus interpretation on a collective approach which may indicate directions for preventive actions. Bonneterre et al. 2011 Developed in nursing research and it is an extended version of NWI-R developed in France with an specific occupational health purpose (9) Ward Organization Features Scale (WOFS) - to identify the “sociotechnical work environment” of acute care hospitals Adams & Bond 2000 Nursing research (10) Work Quality Index (WQI) - to measure nurses’ satisfaction with the quality of their work and work environment Whitley and Putzier 1994 Nursing research (11) Essentials of Magnetism (EOM) tool Kramer and Schmalenberg 2005 Nursing research (12) Assessment of Work Environment Schedule (AWES) - to measure nurses’ work environment on nurse job satisfaction and morale Nolan et al. 1998 Psychology (13) Work Environment Scale (WES) – assess the social climate of work settings, including relationships among employees, between employees and supervisors, and the unit’s organizational structure and functioning Dickens et al. 2005, Hayhurst et al. 2005 Psychology 10 2.3.2 Revised Nursing Work Index In the current study, the Revised Nursing Work Index (NWI-R) was utilized to describe and compare the professional practice environment of RNs in participating countries. The NWI-R has been used in numerous studies to measure the presence of organizational attributes that comprise a professional nursing practice environment, and it has shown reliability and validity for a variety of samples of hospital nurses (Aiken & Patrician 2000). NWI-R was developed from the Nursing Work Index (NWI) (Kramer and Hafner 1989). The NWI itself was developed on the basis of job satisfaction and work value literature. In addition, the characteristics reported in the Magnet Hospital study were utilized. Magnet Hospitals were identified based on their reputation for good nursing care, low number of vacancies and low turnover rates during a nursing shortage in the US in the 1980s (McClure and Hinshaw 2001). The main difference between the NWI and the NWI-R is that the latter focuses on the presence of specific organizational attributes, rather than nurse satisfaction and perceived productivity associated with these traits. The revised version was developed to study organizational attributes leading to positive patient, nurse and institutional outcomes (Aiken et al. 2002, Budge et al. 2003, Laschinger et al. 2001). Compared to the NWI, the NWI-R contained fewer items (57 statements concerning aspects of the nursing work environment), but otherwise remained the same except that one item was modified and two more were added. Fifteen NWI-R items were categorized on a theoretical basis into subscales known as autonomy, control over the practice setting, and nurse-physician relationships. Ten of these 15 items were clustered in a subscale known as organizational support (Aiken and Patrician 2000, Budge et al. 2003). In summary, the NWI-R deals specifically with factors in the work environment that enhance or interfere with nurses’ ability to provide care. It views nursing as knowledge-based work, involving judgment rather than specified tasks, and managers as professional peers of nurses who are responsible for creating an environment to make this possible (Bonneterre et al. 2011). Respondents completing the NWI-R instrument are asked to indicate, on a four-point scale ranging from strongly disagree to strongly agree, the extent to which each statement is representative of their current work environment. Results pertaining to three subscales of the NWI-R are typically reported: autonomy (five items), indicates independence in making patient care decisions within the scope of nursing practice; control over practice (seven items), refers to exerting influence over others to promote high-quality patient care; and nurse–physician relationships (three items) refers to collegial relationships with medical staff. Organizational support refers to administrative and managerial support for nursing, including the adequacy of resources, opportunities for nurse advancement, and support for continuing education. NWI-R has been shown to exhibit high reliability, validity (face, content, and criterion-related) and internal consistency in scoring, as indicated by Cronbach’s alpha scores (Slater et al. 2010, Vahey et al. 2004). Investigators using the instrument have differentiated between magnet and non-magnet hospitals based on the mean scores of four conceptual constructs within the NWI-R. Moreover, each of the individual items of the NWI-R can be analysed and compared (Aiken et al. 2001). Although most of the research using NWI-R refers to the same four-factor module introduced by Aiken and Patrician (2000), there is also increasing evidence for the value of different factor solutions. To provide a comprehensive overview of the different factor solutions associated with the use of NWI-R, a literature search was performed. The Cinahl and PubMed databases were searched for the following keywords: Revised Nursing Work Index, nurse, practice environment / nursing practice. In addition to Cinahl provided 26 references and PubMed 11 references, a manual search of the references within these papers was conducted, resulting in the identification of three additional studies. All papers were reviewed critically to include only the ones reporting the use of NWI-R 11 among nursing staff. As a result, 16 papers were rejected; the remaining 24 are listed in the table below (table 3). Table 3 Studies (n=24) using NWI-R to investigate the nurse practice environment and the factor structure reported for NWI-R Author Setting, sample, country NWI-R factor structure Aiken & Patrician 2000 40 units from 20 hospitals 4-factor solution 1) autonomy 2) control over practice 3) nurse physician relationship 4) organizational support Taunton et al. 2001 RN n=616 7-factor solution 1) staffing 2) nurse physician relationship 3) management 4) participation 5) professional development 6) professional care system 7) chief nursing officer Estabrooks et al. 2002 RN, n=17 965, Canada 1-factor solution Practice environment index Foley et al. 2002 RN, n=103, from two military hospitals, US 4-factor solution 1) autonomy 2) control over practice 3) nurse physician relationship 4) organizational support Table 3 continues 12 Table 3 continued Author Setting, sample, country NWI-R factor structure Lake 2002 Two samples: 5-factor structure (* referred to as the Practice Environment Scale of the Nursing Work Index (PES–NWI) 1) During 1985–1986, n=2,336, from 16 magnet and eight non-magnet hospitals, n=2,299 (Kramer & Hafner 1989); 2) n=11,636, staff nurses from Pennsylvania’s 210 hospitals (Aiken et al. 2001) Budge et al. 2003 RN n=225, general hospital, New-Zealand 1) nurse participation in hospital affairs 2) nursing foundations for quality of care 3) nurse manager ability, leadership and support of nurses 4) staffing and resource adequacy 5) collegial nurse physician relations 3-factor structure 1) autonomy 2) control over practice 3) nurse physician relationship Laschinger et al. 2003 Study I: Staff nurses n=234; study II: n=263 hospital nurses; study III: n=55, nurse practitioners Ontario, Canada 3-factor structure 1) autonomy 2) control over practice 3) nurse physician relationship Choi et al. 2004 110 ICUs from 68 hospitals, n=2324, US 7-factor structure 1) staffing and resources adequacy 2) nurse doctor relationship 3) nurse management 4) professional practice 5) nursing competence 6) nursing process 7) positive scheduling climate Vahey et al 2004 nurses (n= 820), patients (n=621) from 40 units in 20 urban hospitals, US 3-factor structure 1) staffing adequacy 2) administrative support 3) nurse physician relations Table 3 continues 13 Table 3 continued Author Setting, sample, country NWI-R factor structure McCusker et al. 2004 nurses, n= 243 universityaffiliated hospital, Canada 5-factor structure 1) staffing and resources adequacy 2) nurse-physician relationship 3) nurse manager ability, leadership, support of nurses 4) nurse participation in hospital affairs 5) nurse foundation for quality of care Li et al. 2007 RN n=6 623, from Veteran Health Administration hospitals, US 4-factor structure 1) staffing and resources adequacy 2) nurse physician relationship 3) managerial support 4) opportunity for advancement Slater & McCormack 2007 RN, n=172, acute care hospitals, UK 3- factor structure 1) adequacy of staff and support 2) nurse-doctor relationship 3) nurse management Aiken et al. 2008 RN n=237, 5-factor structure working in general 1) administrative support for nurses medical or surgical inpatient settings, UK 2) career support for nurses 3) working with competent nurses 4) nurse autonomy 5) doctor-nurse relations Flynn & McCarthy 2008 staff-nurses n= 368 and Directors of Nursing n=10, Ireland 4-factor solution 1) autonomy 2) control over practice 3) nurse physician relationship 4) organizational support Kanai-Pak et al. 2008 Staff nurses, n=5,956 from 302 units in 19 acute hospitals, Japan 2-factor structure 1) staffing-resource adequacy 2) nurse physician relations Table 3 continues 14 Table 3 continued Author Setting, sample, country NWI-R factor structure Schubert et al. 2008 Nurses (n=1338), patients (n=779) from 118 medical, surgical and gynaecological units, Switzerland 3-factor structure 1) nursing leadership and professional development: Leadership 2) nursing resources and autonomy: Resources 3) interdisciplinary collaboration and competence: Collaboration Tervo-Heikkinen et al. 2008 RN, n=451, 34 inpatient wards in four university hospitals, Finland 5-factor structure 1) professional advancement 2) support of immediate superiors 3) staffing adequacy 4) respect and relationships 5) standards of professional nursing Van Bogaert et al. 2009a n=155 nurses across 13 units in three hospitals, Belgium 3-factor structure 1) nurse–physician relations 2) nurse management at the unit level 3) hospital management and organizational support * known as NWI-RVL – previously translated and validated NWI-R developed for research in the Dutch speaking part of Belgium Bruyneel et al. 2009 Nurses n=179, acute-care hospitals, Belgium 3-factor solution 1) nurse physician relationship 2) staffing and resource adequacy 3) nurse manager ability, leadership and support of nurses Gunnarsdottir et al. 2009 Nurses in direct patient care, n=695, one university hospital, Iceland 5-factor structure 1) nurse physician relations 2) unit level support 3) staffing 4) philosophy of practice 5) hospital-level support Table 3 continues 15 Table 3 continued Author Setting, sample, country NWI-R factor structure McAuliffe et al. 2009 mid-level health care providers, n=153, Malawi 4-factor structure 1) levels of staffing and resources 2) management support 3) workplace relationships 4) control over practice Roche et al. 2010 Secondary RN data 5-factor structure 1) autonomy 2) leadership 3) resource adequacy 4) control over practice 5) nurse physician relationship Slater et al. 2010 RNs, n= 449, 6-factor structure three acute care hospitals, Northern Ireland 1) staff development and education 2) nursing care 3) adequate staff and support 4) effective relationship between all staff 5) nurse management 6) nursing involvement * also confirmed the three factor structure proposed by Slater & McCormack 2007 El-Jardali et al. 2011 RN, n=1793, from 69 hospitals, Lebanon 6-factor solution 1) autonomy 2) control 3) nurse physician relationship 4) organizational support 5) career development 6) participation 16 Despite linguistic and cultural differences and lingering controversies about the associated factor structure (e.g. Slater & McCormack 2007), the NWI-R remains the bestvalidated and most extensively used measurement tool in small and large scale research projects investigating the nurse practice environment internationally (van Bogaert et al. 2009a, 2009b). 2.4 COUNTRY PROFILES OF THE THREE COUNTRIES A health system is the creation of the human community, and the health system of any society can only be understood in the light of its societal operating principles and policies (Sund 2008). By today, European Union (EU) comprises of 27 member states with total about 499 million inhabitants. The levels of per capita national wealth vary considerably in the EU. There are large differences in health care expenditure across different countries and they cannot be explained entirely by the demographic, economic or technological differences. Legal and institutional architecture of health care provision and financing is undoubtedly an important factor influencing the public and private spending in the sector. However, high complexity of the system and variety of its features makes it very difficult to quantify and compare across the countries. On a broader scale, a conservative estimate of the size of the health workforce is 11 million workers in European countries, of which 56% are nurses (Wismar et al. 2011). To provide a perspective on the relevance of investigating the professional practice environment of hospital nurses in Finnish, Dutch and Estonian contexts, the short descriptions of each country’s nursing workforce situation are outlined, along with future challenges. Table 4 presents comparative, country-specific health profile data for Finland, The Netherlands and Estonia. Table 4 Overview of the country-specific health profiles of Finland, The Netherlands and Estonia Health profile indicators The Netherlands Estonia 5 365 000 16 613 000 1 341 000 % of population aged 0-14 years (2009) 17 18 15 15.6 % of population aged 65+ years (2009) 17 15 17 20.1 Life expectancy at birth (years, both sexes) (2009) 80 81 75 75 Population living in urban areas (%) (2009) 64 82 69 70 35 280 39 740 19 120 23 530 Total expenditure on health as % of GDP (2008) 8 9 6 8.3 Number of physicians / Number of nurses per 1000 population (2009) 3.29 / 8.55 3.93 / 15.05 3.29 / 6.55 3.21 / 7.47 Hospital beds per 100 000 (2009) 622 468 544 551 Total population (2010) Gross national income per capita (PPP international $) (2009) Finland EU average Sources: WHO Regional Office for Europe 2009; Eurostat 2009; OECD 2010; 17 2.4.1 Overview of the health care systems Finland. Finland has a compulsory, tax-funded health care system, which provides comprehensive cover for the entire resident population. There are three main systems providing health care services in Finland: municipal, occupational and private health care. It has been argued that public responsibility for health care is decentralized in Finland more than in any other country (Häkkinen & Lehto 2005). Municipalities are responsible for organizing and funding health services for their inhabitants. Each municipality is a member of one of the 20 hospital district joint authorities, which are responsible for organizing specialized medical services and coordinating hospital treatment in their own district. The largest hospital district in terms of the population base has over 1.4 million inhabitants, while the smallest has only 65 000. The number of member municipalities covered by the hospital district varies from 6 to 58. Secondary and tertiary level medical care is provided by a hierarchy of regional, central and university hospitals. Five of the central hospitals are university teaching hospitals. All personnel in the public hospitals are salaried employees of the hospital districts (Vuorenkoski et al. 2008). There have been many recent reforms to the Finnish health system, including the setting of thresholds for admission onto waiting lists for elective surgical procedures, the introduction of a set of maximum waiting-time targets for non-urgent examinations and treatment, a national electronic patient record system and a project aiming to restructure both municipalities and services (Sund 2008). The Netherlands. A major health care reform in 2006 has brought completely new regulatory mechanisms and structures to the Dutch health care system. The reform introduced a single compulsory insurance scheme, in which multiple private health insurers compete for insured people. Responsibilities have been transferred to insurers, providers and patients, and the government only controls the quality, accessibility and affordability of health care (Schäfer et al. 2010). From an international perspective, financial and human resources allocated to health care seem sufficient to meet the needs of the population (Schäfer et al. 2010). Health care can be divided into preventive care, primary care, secondary care and long-term care. Secondary care is only accessible upon referral from a primary care health provider, such as a general practitioner, dentist or midwife. Due to mergers, many hospitals are large-scale organizations and operate nowadays from more than one location. Mergers were driven by market strategy, as well as the importance of obtaining sufficient countervailing market power against health insurers. In 2009, there were 141 hospital locations and 52 outpatient clinics within 93 organizations, among them eight university hospitals. Most hospitals are non-profit corporations (Schäfer et al. 2010, Westert et al. 2008). There are six types of institutions that provide hospital or medical specialist care: (1) general hospitals, (2) academic (university) hospitals, (3) categorical hospitals (they concentrate on specific forms of care or on specific illnesses, e.g. revalidation, asthma, epilepsy or dialysis), (4) independent treatment centres (the care provided is limited to the so-called B-segment, which means non-acute, freely negotiable care that can be provided through one-day admissions), (5) top clinical centres (specializing in e.g. cancer, organ transplantation, in vitro fertilization (IVF); most of those centres are part of a university hospital or are operated by a number of hospitals working cooperatively), and (6) trauma centres (mostly related to a university hospital). In addition to general and university hospitals, independent treatment centres have become part of the acute hospital sector (Schäfer et al. 2010, Westert et al. 2008). Estonia. The Estonian health care system is mainly publicly funded through solidaritybased mandatory health insurance contributions in the form of an earmarked social payroll tax, which funds almost two thirds of the total health care expenditure. The organization of the current health care system dates back to the 1990s. During the second legislative review, 2000–2003, various areas including health financing, service provision 18 and regulation of relations between different actors (e.g. purchaser, provider and patient) were addressed. Further adjustment to regulation has been implemented to harmonize the framework with EU legislation and to respond to emerging needs; this has happened continuously since 2004 (Koppel et al. 2009). Active treatment hospitals are divided into regional, central, general and local institutions. Further, there are also specialized, rehabilitation care and nursing care hospitals. Each active treatment hospital covers a particular area or region. The location has been chosen so that active treatment is available to everyone within a minimum distance of 70 km or 60 minutes’ drive. At the end of 2006 there were 55 hospitals in Estonia: 20 nursing care hospitals, 12 general hospitals, 7 special hospitals, 6 local hospitals, 4 central hospitals, 3 rehabilitation care hospitals and 3 regional hospitals. Most hospitals are owned by local government, although regional hospitals were originally established by the State (Jesse et al. 2004, Koppel et al. 2009). 2.4.2 Nursing workforce profiles Finland. In Finland there is no state level direct mechanism to steer strategic human resources for health either geographically or by level of care, except to influence the education of health professionals, including nurses. The training of nurses takes place at polytechnic level. The training programme lasts three years for nurses, three and a half years for public health nurses and four and a half years for midwives. Assistant nurses are trained in a two and a half-year programme. There are university-level programmes of nursing science and health sciences (bachelors and masters degrees). Legally, health centres and hospital districts are responsible for arranging continuous education for their personnel (Vuorenkoski et al. 2008). Despite a significant rise in the number of Finnish nurses since 1990, health care providers are now finding it increasingly difficult to recruit enough nurses. A relatively large proportion of Finnish nurses have moved to work in fields other than health care or work abroad. The shortage of professionals may turn out to be a critical factor in the development of Finnish health care. Due to its older population structure, Finland is about to enter an era of a declining labour force that will lead to a general increase in competition for workers: about 40% of active health professionals are over 50 years of age. There is a great need for a clear national strategy for human resources in health care. It is unlikely that hiring foreign clinicians alone will solve the problem. Efforts should be made to improve the attractiveness of health care as a long-term career (Teperi et al. 2009). The Netherlands. The Dutch health care workforce is diverse, segmented, changing rapidly and it largely follows national demographic trends. About 7% of the population works in the health care sector and since the early 2000s the total number has grown by about one-fifth. This means that studying its structure and dynamics is important in order to correctly forecast future demand. Although much effort is put into avoiding labour market shortages, in some sectors mismatches between supply and demand appear to have become structural. For instance, shortages of nurses in homes for the elderly and in nursing homes (the largest and fastest-growing sector) pose major workforce problems (Westert et al. 2008). Compared to other countries, the relative number of nurses is particularly high. In the late 2009s substitution and transfer of tasks from medical to nursing professionals was an important trend. The quality of health care professionals is safeguarded by obligatory registration and by various licensing schemes maintained by professional associations (Schäfer et al. 2010). Health workforce planning is an important instrument for forecasting and controlling shortages and oversupply. For the nursing sector a programme, called regiomarge, exists through which national, regional and local organizations can monitor relevant labour market developments and in which forecasts are made (by Prismant) about the balance between supply and demand for various types of nursing professionals. This system is an initiative of different organizations in the sector. Nurses can either be educated at an intermediate, higher or academic level, depending on their professional profile. Basic 19 training for nurses usually takes place within vocational training institutes and is financed by the Ministry of Education, Culture and Science. Entrance can be restricted, but usually no external limitations are set. Training institutes can then set their own entrance volume (Schäfer et al. 2010). It is remarkable that, with regard to the nursing workforce, the inflow of foreign-trained nurses has been quite low and has even exhibited a fall. This may be because most EU countries suffer from shortages, which makes recruiting nurses from abroad difficult (Westert et al. 2008, Schäfer et al. 2010). Estonia. The number of nurses remains a major area of concern. At present, there are approximately two qualified nurses employed per doctor. The present ratio of nurses to doctors is considered to be too low, and the officially declared aim is to raise the ratio to 4:1. The aim is 8.0 nurses per 1000 residents by 2015. To meet this goal the annual intake of nurses should also rise, but the lack of financial and human resources may compromise this goal. However, it is obvious that trying to keep the existing number of nurses, requires a decrease the number of nurses dropping out of school or professional work; this could be achieved through political instruments, including higher salaries and improved working conditions (Koppel et al. 2009, Saar & Habicht 2011). The number of registered health care workers is (still) higher than actual employment levels in the Estonian health care sector. For example, 21% of the qualified and registered nurses do not actually work in the health care sector, but rather in the pharmaceutical or cosmetics industries. Between 2004 and 2006, nurses working outside the health care sector posed a larger problem for the sustainability of the Estonian system than professional migration of health workers (2% of nurses) (Saar & Habicht 2011). Estonia only began to collect migration statistics in May 2004. The Health Care Board (HCB) has information about the number of doctors, nurses and other health care professionals who wish to take up and pursue a profession in another Member State, as expressed by the numbers of certificates (of conformity of study) issued, required for working abroad. According to EC Directive 2005/36 the issued certificates enable health care workers to start a recognition procedure in another Member State. However, these data may be misleading and provide only a partial picture of the situation because the HCB does not have exact feedback on whether health care professionals have actually migrated to another Member State. The number of health care workers that have actually migrated is approximately 3.3% of the total number of health care workers who are working in the health care sector. When HCB analysed the destination countries, it discovered that the five most popular locations were Finland, the United Kingdom, Sweden, Germany and Norway (Koppel et al. 2009). The combined effect of the three factors, dropping out of the health care sector, migration and retirement, will inevitably reduce the numbers of nurses in Estonia in the near future, since the growth in numbers of new nurses has been below the replacement level. In 2006, 175 new nurses joined the health care sector, while nurses with a desire to work abroad and work outside the health care sector amounted to 63 and 1725, respectively. According to HCB data, 59% of 65-year-old nurses continue to work. This helps to mitigate the negative effect of the decreasing number of health care workers caused by ageing, insufficient numbers of graduates and migration (Koppel et al. 2009, Saar & Habicht 2011). 20 2.5 SUMMARY OF THE THEORETICAL BASIS OF THE STUDY Understanding how nurses perceive their professional practice environment, and targeting strategies to improve those characteristics are essential in the retention of nurses, and determining quality of care delivery; The challenges RNs face in their practice environment are very similar across countries despite differences in resources and the design of national health care systems. Nurses commonly express increasing concern about their ability to deliver quality care as a result of decreases in staffing levels, inappropriate skill mixes and altered organizational design; Nurse staffing in hospital settings is in the spotlight because of the growing consensus that adequate staffing is associated with the quality of patient care; Nurses make important contributions to health care outcomes and outcomes are affected by the environment in which care is delivered; Hospital nurses’ work environments are associated with both nurse job outcomes and patient outcomes; It is important to understand the European perspective on this topic. Reductions in hospital inpatient capacity have been common for more than a decade for most of European Union member countries. In addition, various managerial reforms have been undertaken to improve productivity in the hospital sector. These initiatives have taken different forms, some focusing on new organizational arrangements such as vertical and horizontal integration of services, mergers, and regionalization of services, and others on process re-engineering and work redesign. Hence RNs’ perceptions of their professional practice environment are in focus. RNs are valuable informants because of their close proximity to patients and because their work brings them into contact with managerial policies and practices, physicians and other clinical care providers, and most hospital support services. 21 3 Purpose of the study The purpose of this study was to examine RNs practice environment in hospital settings in Estonia, Finland and The Netherlands. Furthermore, to investigate the relationships between practice environment and nurse reported job and patient outcomes, as well as to assess the effects of various staffing patterns on patient outcomes in Finnish and Dutch hospital context. Research questions were: 1) Which organizational attributes characterize nurses’ professional practice environment in the hospital settings in Finland, Estonia and The Netherlands? (Paper I, II, III, summary) 2) What is the relationship between the professional nursing practice environment and nurse-reported job outcomes (e.g. job-related feelings, intentions to leave, adverse incidents affecting nurses, provided quality of care) as perceived by registered nurses in Finland and The Netherlands? (Paper III) 3) What nurse staffing patterns (including patient to RN ratios, nursing staff mixes and nurse-evaluated adequacy of support services) occur in hospital settings in Finland and The Netherlands? (Paper IV) 4) What is the relationships between nursing activities, nurse staffing patterns and adverse patient outcomes in hospital settings as perceived by registered nurses in Finland and The Netherlands? (Paper IV) The aims of the present study were to provide international perspectives on nursing worklife issues in hospital settings, and produce knowledge for evidence needed in future nursing workforce strategies to enhance the performance of hospitals and health systems. 22 4 Methods 4.1 DESIGN A multi-country, cross-sectional survey design was used for data collection (Figure 1). The study design supported the multidimensional conceptualization of nurses practice environment and relied partly on the theoretical model proposed by Mark and colleagues (2003) of the relationships between context, structure (professional practice) and effectiveness. Literature review on organizational attributes of professional nursing practice environment RN survey in hospital settings Finland (n=535) Estonia (n=478) April-Juni 2004 Nov.2005Feb.2006 Purpose of the study: To examine RNs practice The Netherlands (n=334) Context Nov.2005-Jan.2006 Workforce: nurse staffing pattern Structure environment in hospital settings in Estonia, Finland and The Netherlands; and To investigate the relationships Work content: daily work design Workplace: nonuniversity & university hospitals between practice environment and nurse reported job and patient outcomes, as well as to assess the effects of various staffing patterns on patient outcomes in Finnish and Dutch hospitals. Nurse-reported job and patient outcomes: Quality of care Job related feelings, Intention to leave, Adverse events (nurse, patient) Figure 1 Study design Effectiveness (outcome) 23 4.2 SAMPLE, SETTING AND DATA COLLECTIONS Data were collected from three European countries: Finland, The Netherlands and Estonia. The study involved RNs working in hospital settings in those selected countries. It should be that staff nurses can be accurate informants about hospital characteristics because their scope of work is broad and brings them into contact with most aspects of the organization, and, in addition, they are directly involved in clinical decision making (Aiken & Patrician 2000). Data collection in Finland: There were 41,300 members of the Finnish Nurses’ Association at the time the study sample was drawn (April–June 2004). The target population covered 18,700 members from whom 3000 members in clinical work were randomly selected. In total, 1192 of them returned the questionnaires. For the study, secondary data were used and only RNs working in hospitals (academic-teaching, central and other hospitals) were included (n = 535), with an overall response rate of 44.9%. Data collection in The Netherlands: There were 24,000 members of the National Nurses Association of the Netherlands, Nieuwe Unie’91 (NU’91) at the time the study sample was drawn. A random sample (n = 1000) of RNs employed in hospitals from this database was included. The overall response rate was 33.4% as 334 RNs returned completed questionnaires. The survey was conducted during the period between November 2005 and January 2006. Data collection in Estonia: The data were collected by PRAXIS (Estonian Centre for Policy Studies). Data collection was carried out during the period November 2005 to February 2006. A nationwide survey examining the characteristics and perception of nurses’ work environment, its impact on nurses’ professional motivation, and its relationship with migration plans and nature of their workplace was conducted (see for details Paper I). Since the questionnaire also included the NWI-R as a measurement tool to examine RNs’ perceptions of the organisational attributes that characterise their professional practice environment in Estonian acute care hospitals (regional, central and general hospitals), only this part of the questionnaire together with participants background data was utilized in the current study. 4.3 VALIDITY AND RELIABILITY OF THE INSTRUMENT The original questionnaire used in this study for data collection in Finland and The Netherlands was initially developed in the Finnish language by experts in the HELMIproject (Staffing Measurement project) team in Finland (Partanen et al. 2005, TervoHeikkinen et al. 2008). The Finnish and Dutch instruments were nearly identical, but the one used in Estonia involved only one cross-country overlapping measurement, the NWIR. Minor modifications, related to local health care practices and nursing education systems mainly concerning background information, were made to the instrument used in The Netherlands. In an attempt to increase external validity, written instructions were supplied to the respondents. Content validity relied on the fact that the instrument used was developed on the basis of existing literature and tools (e.g. the NWI-R of Aiken & Patrician 2000 and the nurses' work condition parameter of Partanen et al. 2005). In order to examine internal consistency, Cronbach alpha values were calculated for the data. The alpha values for the professional practice environment scale varied between 0.75 (Finnish data) and 0.79 (Dutch data), see details Paper IV. Estonian data are presented in Paper I. Pilot testing of the instrument was part of the translation process. 24 4.3.1 Instrument translation process Translation was considered a very important factor in assuring the validity and reliability of the instrument. Translating the questionnaire for international comparative research is complex and time-consuming, but an essential step in the research process. As discussed in previous literature, developing a culturally equivalent translated questionnaire requires familiarity with basic problems of linguistic adaptation, cultural constructs and psychometric changes inherent in the translation process. Beside linguistic knowledge, it is equally important to be familiar with the health care system in the country of interest (Maneesiwongul & Dixon 2004). Before the translation commenced, a literature review was undertaken in 2006. The aims of the literature review were to identify various questionnaire translation methods used in published nursing research (1998-2005) and to examine the factors influencing the selection of translation method. The final objective was to develop a questionnaire translation approach that was suited to the current study context. Based on an extensive literature review (involving the Cinahl and Medline databases and a manual search) of studies involving translation of quantitative research instruments, the strengths and weaknesses of each method were analysed. The following keywords were used to acquire the data: instrument/questionnaire translation, back-translation, instrument translation process, adaptation/adoption of questionnaire, combined with crosscultural study, cross-national survey, international collaborative study and international comparative study. Papers were included when they fulfilled certain selection criteria: papers describing the whole translation process, in the English language. The total number of studies included in the literature review was 14, comprising 13 survey studies and one systematic review. As a result, six main translation methods that are widely used in nursing research were identified: forward translation – alone and with pilot-testing; back translation – alone and with monolingual pilot-testing or bilingual pilot-testing; and the combined method: back translation with mono- and bilingual pilot–tests. A wide range of factors influenced selection of an appropriate translation method. These factors were: the objectives of the study; the nature of the source instrument; the availability of translators; the availability of bilingual subjects; budget; and time (Gudmundsdottir et al. 2004, Maneesiwongul & Dixon 2004). Furthermore, evaluation of the translated questionnaire involved assessing validity, reliability, sensitivity to change and international equivalence issues. Equivalence is defined as the degree to which survey measures or questions are able to assess identical phenomena across two or more cultures. There are five dimensions of equivalence to be considered: content, semantic, technical, criterion and conceptual equivalence (Harkness et al. 2003). The questionnaire translation approach used in this study involved two stages: forward translation (four-phases including a pilot-study) and back translation (four-phases). This approach was used when translating the original Finnish questionnaire into Dutch. It is important to emphasize that translated questionnaires should be treated like new instruments. There were five basic procedures involved in producing the final version of the translated instrument: translation, assessing the translation (review), decisions about version, pilot testing and documentation. 25 4.4 DATA ANALYSIS Data were analysed using the SPSS 14.0 and 17.0 programmes. Several statistical tests were performed on the data. Detailed descriptions are presented in Papers I-IV. An overview of the sampling and data analysis methods for each study, including a summary, are presented in Table 5. Table 5 Sampling and data analysis methods for each study Paper and focus Sample Analysis methods I Nurses' perceptions of the organizational attributes of their practice environment in acute care hospitals Stratified random sample of 478 acute-care hospital RNs, Estonia Descriptive statistics, mean scores, Spearman’s correlation, Kruskal-Wallis H test II Hospital nurses’ work environment, quality of care and career plans RN survey, n = 334 working in academic and district hospitals in The Netherlands Descriptive statistics, exploratory factor and regression analysis III The professional nursing practice environment and nursereported job outcomes in two European countries: a survey of nurses in Finland and The Netherlands RN survey, n=535 from Finland and n=334 from The Netherlands, Descriptive statistics, exploratory factor analysis, logistic regression analysis, IV Nursing activities, nurse staffing and adverse patient outcomes as perceived by hospital nurses RN survey, n=535 from Finland and n=334 from The Netherlands, Descriptive statistics, exploratory factor analysis, Pearson-correlation, t- and chisquare tests, analysis of variance. Summary Nurses' perceptions of the organizational attributes of their practice environment in three countries RN survey, n=535 from Finland, n=334 from The Netherlands, n=478 from Estonia Descriptive statistics, confirmatory factor analysis, structural equation modelling T-tests 4.5 ETHICS OF THE STUDY As this study was conducted in three different countries, local rules and ethical guidelines were followed. For the data collection in Finland, ethical approval was given in 2004 (for the whole HELMI-project). In The Netherlands, permission to conduct the study among registered nurses working in the hospital settings was given by the board of the Dutch Nurses Association, NU’91 (May 2005). In Estonia, ethical approval was given by the Bioethical Committee of Tartu University, Estonia (September 2005) to the Estonian Centre for Policy Studies (the collaborator in the Estonian study). Participation in the study was voluntary and participants were given information about the study via an accompanying letter. Participants were anonymous and personal data were handled with care. Completed questionnaires were only used by the researcher(s) and people involved in the study project(s). Consent to use the questionnaire in data collection in The Netherlands was provided by the Finnish Nurses Association which holds the copyright of the original questionnaire. 26 5 Results 5.1 DEMOGRAPHIC, EMPLOYMENT AND NURSE STAFFING CHARACTERISTICS The study sample comprised RNs working in direct patient care in hospitals in three European countries: 535 from Finland, 334 from The Netherlands and 478 from Estonia (table 6). There were significantly more male nurses (χ2(1,N=869)=17.08,p=0.0005) from The Netherlands (10%) than from Finland (3%) and Estonia (1%). Similar proportion of Finnish (46%) and Estonian (44%) RNs, but more Dutch RNs (61%), were younger than 41 years old. Although the majority of RNs from all countries had worked in nursing for more than five years, a statistically significant difference in experience was found (p=0.0005): there were fewer Estonian novice RNs (11%) and more highly experienced RNs, i.e. with more than 31 years of nursing (26%). Nearly all of the Dutch RNs (97%) and three quarters of Estonian participants (75%), but fewer Finnish RN (60%) worked in non-university hospitals. Most of the Finnish (92%) and Estonian respondents (91%) worked full-time, but more than half of their Dutch counterparts (57%) worked part-time (p=0.0005). 27 Table 6. Sample characteristics Measure Finland The Netherlands Estonia (n=535) (n=334) (n=478) % % % 3 10 1 Female 97 90 99 ≤30 years 23 33 15 31-40 years 23 28 29 41-50 years 31 25 26 51-60 years 23 14 21 0 0 9 ≤5 years 28 27 11 6-10 years 21 12 10 11-15 years 14 17 16 16-20 years 14 14 13 21-25 years 9 10 16 26-30 years 6 11 8 ≥31 years 8 9 26 University hospital 40 3 25 Non-university hospital 60 97 75 Full-time 92 43 91 Part-time 8 57 9 Gender Male Age ≥61years Years of experience in nursing Type of hospital Working full-/ part-time 28 The most recent shift worked by the respondents was the morning/day shift, with 52% of Dutch RNs, 43% of Estonian and 64% of Finnish RNs. The average distribution of the patient to RN ratio per country and per morning/day shift is shown in Table 7 below. Table 7 Patient to RN ratios of participants in The Netherlands (n=334), Finland (n=535) and Estonia (n=478) The Netherlands Finland Estonia Morning/Day shift (n=174) Morning/Day shift (n=342) Morning/Day shift (n=206) % % % 4:1 34 32 36 5-9:1 27 18 20 ≥10:1 39 50 44 9.55(10.33) 11.84(10.44) 10.47(10.09) Patient to RN ratio Mean (SD) Some additional work-related data were gathered from the Dutch and Finnish participants. This showed that there was not statistically significant (t(798)=0.90, p=0.369) difference between RNs on staff in the Dutch hospitals compared with the Finnish ones. The proportion of licensed practical nurses (LPNs) appeared to be significantly higher in Dutch than in Finnish hospitals: t(602)=-2.10, p=0.036. Respondents were asked about the ideal nursing staff mix and, on average, their opinion was that one or two more nurses were needed in their respective units. 5.2 HOSPITAL NURSES’ PRACTICE ENVIRONMENT Paper I illustrates Estonian RNs’ perceptions of the organizational attributes of their practice environment in acute care hospitals. Nurse autonomy, control over practice, nurse-physician collaboration and organizational support were investigated as being important factors in ensuring a positive nursing practice environment. This four-factor structure of the NWI-R subscales is based on the one proposed by Aiken and Patrician (2000) and derived from the literature. In the second Paper, practice environment characteristics were derived from the data describing Dutch nurses’ perceptions. The following five-factors were identified: (1) support for professional development; (2) adequate staffing; (3) assuring nursing competence; (4) supportive management; and (5) teamwork with physicians. The findings presented in the third Paper concerning the practice environment were derived from the RN data involving participants from Finland and The Netherlands. A three-factor structure was identified: adequacy of resources, supportiveness of management and assurance of care quality via collaborative relationships. Because the published papers did not include comparison of data from all three countries, this summary attempts to fill this gap. Therefore, as a first step, the RN practice environment was examined from two perspectives: first, the four-factor module proposed by Aiken and Patrician (2000), and second, a data-based four-factor structure that was identified. Both analyses were conducted using aggregated data (including all data from Dutch, Finnish and Estonian RNs). The data-derived analyses were performed in order to test the model fit. The factor structure that has, to date, been associated with the NWI-R is unstable. Thus, it can be presumed that the questionnaire is sensitive to cultural differences and that the factor structure with the best fit varies between settings and countries. It was, therefore, preferable to conduct separate factor analyses and compare the 29 results using multi-group confirmatory factor analysis. The original four-factor structure of Aiken and Patrician’s (2000) to illustrate the RN practice environment failed to provide a good model fit (χ2 =3677.60, χ2 p-value = <0.0005, df=127, RMSEA=0.147, AGFI=0.723) when tested against the aggregated data. Hence, the result presented here reflect the databased four-factor structure that was identified. To identify the factor structure present in the aggregated data (including all three countries), exploratory factor analysis was performed. The final item set for each extracted factor was examined in order to identify the following four subscales: (1) supportive management; (2) nurse involvement – acknowledgement of nurses’ professionalism; (3) assuring quality of care; and (4) adequate resources (table 8). The composite scale explained 60.52% of the total variance and it was internally stable, having a Cronbach alpha value of 0.90. Each subscale consisted of five to twelve items. The subscales had moderate Cronbach alpha values, ranging from 0.72 to 0.86. The correlations between the subscales were all significant at the 0.01 level. There were significant differences between the three countries with respect to the mean values of nurses’ perceptions. The differences between the countries were significant for RNs’ perceptions of the supportiveness of management (p=0.0005). While RNs from Estonia acknowledged that they received support from their managers, their Finnish colleagues expressed more criticism concerning this aspect of the work environment. There was no significant difference between Finnish and Dutch RNs’ evaluations concerning nurse involvement (p=0.319). Estonian RNs were more critical, expressing more negative perceptions about this aspect (p=0.0005). With respect to assurance of quality, the Estonian and Finnish RNs were equally positive and there were no statistical differences between their perceptions (p=0.873). In contrast, the perceptions of Dutch RNs differed significantly from the two others (p=0.0005). The subject of whether resources were adequate was also associated with significant differences between the countries (p=0.0005). Dutch RNs were most positive, followed by Estonians; their Finnish colleagues were most critical. After identifying the best factor structure, the next step was to conduct the SEM analysis. In the SEM analysis, the four factors were allowed to be correlated and all measurement error variances for the indicators were left free to be estimated. To evaluate the model, various statistics and measures of fit were examined. As suggested in previous literature, the chi-square (χ2) test (which indicates minimal difference between the model and data when not statistically significant) was not used to evaluate goodness-of-fit because of its sensitivity to sample size. The likelihood that it will indicate poor fit in tests of models with samples containing more than 200 values was confirmed in the current study. For this reason, the Root Mean Square Error of Approximation (RMSEA), a measure of the lack of fit between the data and a model, and the Adjusted Goodness of Fit Index (AGFI), a measure which takes into account the degrees of freedom available for testing the model, were used. Although this model’s value of χ2 was 5333.665 (df=667), with a p-value <0.0005, indicating that the model did not fit the data, the values of AGFI (0.800) and RMSEA (0.073) indicated that the model fitted the data moderately well. The RMSEA value about 0.08 or less, suggests a reasonable error of approximation. The AGFI value of 0.800 is relatively close to the rule of thumb value of 0.90. The closer the AGFI value is to 0.90, the higher the probability that the models indicate a good fit. It is noteworthy that all the estimates for the standardized regression weights were above 0.45. The statistically significant correlations between supportive management, adequate resources and nurses’ had correlation coefficients of 0.40, 0.45 and 0.41 respectively. The correlation between nurses’ involvement and quality of care had a coefficient of 0.37. The correlation between supportive management and quality of care had a coefficient of 0.38. Adequate resources was rather less well correlated with the remaining two factors, namely quality of care (0.26) and nurses’ involvement (0.29). 30 Table 8 The elements of nurses work environment based on the combined data The elements of nurses work environment Factor loadings Alpha value Supportive management 0.86 Nurse manager is a good leader an manager 0.631 Active in-service / continuing education programme 0.618 Administration that listens and responds to employee concerns 0.617 Career development / clinical ladder opportunities 0.611 Opportunities for advancement 0.567 Nursing staff is supported in pursuing degrees in nursing 0.564 Supervisory staff is supportive to nurses 0.562 Chief nurse manager is highly visible and accessible 0.556 Nurse manager consults with staff daily 0.535 Flexible work schedules are possible 0.517 Nurses are actively involved in planning their work schedules 0.501 An active quality assurance programme 0.455 0.81 Nurses involvement – acknowledgement of their professionalism Nursing staff have an opportunity to serve on hospital and nursing committees 0.719 Staff nurses are involved in the internal governance of the hospitals 0.613 Nurses actively participate in efforts to control costs 0.574 Staff nurses participate in selecting new equipment 0.565 Nurses’ input is publicly acknowledged 0.562 Nursing controls its own practice 0.557 Opportunity for staff nurses to participate in policy decisions 0.546 Praise and recognition for a job well done 0.483 Patient assignment fosters the continuity of care 0.458 Table 8 continues 31 Table 8 Continued The elements of nurses work environment Factor loadings Quality of care/collaboration 0.72 Working with nurses who are clinically competent 0.617 Medical care is of high quality 0.554 Good relationships with other departments 0.518 Care plans are up-to–date 0.515 Working together with nurses who know the hospital 0.512 Physicians and nurses have good working relationships 0.504 High standards of nursing care are expected by the administration 0.485 Much team-work with nurses and physicians 0.483 Adequate resources 0.79 Enough nurses on staff to provide quality patient care 0.749 Enough staff to get work done 0.740 Adequate support services 0.658 Enough time and opportunities to discuss patient care problems with other nurses 0.643 A satisfactory salary 0.556 Total scale (34 items) Alpha value 0.90 32 5.3. RELATIONSHIPS BETWEEN THE NURSE PRACTICE ENVIRONMENT AND JOB OUTCOMES Nurse-reported job outcomes provided an indication of nurses’ reactions to their work (positive/negative feelings, intention to leave) and work-related outcomes resulting from the nursing work process, such as adverse events and the quality of care. RNs’ intentions (no intention versus some intention) with respect to their current job were investigated at three levels: intentions to leave their current unit; intention to leave their organization; and intention to changing their profession (see Paper III). The findings of this study indicated clearly that RNs’ perceived positive and negative feelings related to characteristics of their job. Examining the impact of the practice environment on such feelings produced fairly similar findings among participants from Finland and The Netherlands. Adequacy of resources was a significant (p<0.05) predictor of negative job-related feelings across the countries. Positive feelings among Finnish RNs were predicted by supportive management (p=0.02). There appeared to be statistically significant (p=0.0005) differences between the countries with respect to RNs’ intentions to leave their current working unit and organization. Finnish nurses expressed such intentions more often than their Dutch colleagues. Intention to leave nursing appears to be a matter of concern equally in both countries. Some impact of the practice environment was detected, via logistic regression analysis, in the data from both countries, though with some differences in nuance. At the unit level, the supportiveness of management among Dutch RNs (OR=0.52, 95% CI 0.320.90) and the adequacy of resources (OR=0.35, 95% CI 0.23-0.54) among Finnish RNs could act as predictors of nurses’ intentions to leave. Intentions to leave the organization were predicted for Dutch RNs by the adequacy of resources (OR=0.27, 95% CI 0.14-0.52) and among Finnish RNs by both the practice environment characteristics already mentioned (OR=0.51, 95% CI 0.33-0.78 and OR=0.53, 95% CI 0.35-0.79, respectively). Concerns about leaving the nursing profession are significantly related to these two practice environment characteristics in both countries. Although the scores for nurses’ perception of the occurrence of adverse events ranged from 0 to 10, with means of 1.53 and 2.16 for Finnish and Dutch RNs, respectively (t(133)=2.41, p=0.017), there was, notably, no link detected in the logistic regression analysis between the practice environment and adverse events affecting RNs. In addition, adjusting for RN characteristics (such as age, working experience in nursing and employment: fullor part- time) had no impact on this association. With respect to the impact of the professional practice environment on nurses’ assessments of quality of care, some significant relationships were detected in both countries. In addition to the adequacy of resources across participating countries, in the Finnish data the collaborative relationships and in the Dutch data the supportiveness of management had significant (p=0.005) impacts. 5.4 NURSING ACTIVITIES, RN TO PATIENT RATIOS AS STAFFING INDICATORS AND ADVERSE PATIENT OUTCOMES NURSE 5.4.1 Distribution of RNs’ daily activities in hospital settings Nursing activity data were gathered from the Finnish and Dutch participants to gain information about the distribution of the daily nursing practices in hospitals in the participating countries. To investigate the nursing activities that the RNs perform, two sets of items were included: their evaluations of whether they had enough time to perform the listed nursing tasks; and the tasks RNs performed each day (see also Paper IV). There were significant differences between Dutch and Finnish RNs’ evaluations of whether they had enough time to perform the nursing tasks listed (Paper IV, Table 2). 33 Differences in the nursing activities reported by the Dutch and Finnish RNs provided a clear indication that the context (e.g. type of hospital and the countries’ health care system) influences daily nursing practice. Using exploratory factor analysis, three kinds of daily activities for RNs’ were identified: 1) nursing activities (e.g. IV cannulation and starting IV-infusion, medication, blood transfusion, wound care etc.); 2) non-nursing activities (such as delivering food and clearing up afterwards, transporting patients, making beds and changing bed linen); and 3) administrative activities (such as making appointments for patients, ordering bed linen and laboratory tests, making rosters and organizing patients’ discharge papers). The composite scale was internally stable, having a Cronbach alpha value of 0.84, with subscale values ranging from 0.71 to 0.80. Findings relating to the differences between the countries are presented in Paper IV. 5.4.2 Nursing activities and relationships with the patient to RN ratio In this study, the RN to patient ratios were used as nurse staffing indicator. There was no statistical difference found between the countries (t(798)=0.90, p=0.369). The proportion of licensed practical nurses (LPNs) was significantly higher in Dutch hospitals than in Finnish hospitals: t(602)=-2.10, p=0.036. Respondents were asked about the ideal nursing staff mix and, on average, their evaluation was that one or two more nurses were needed in their respective units. Significant (p=0.005) differences between the countries appeared with respect to the presence of adequate support services in the units to allow RNs to spend sufficient time with their patients. Corresponding data about these results can be found in Paper IV, table 1. The results provide evidence that, regardless of the country, the patient to RN ratio was significantly related to RNs’ concerns about the time available to perform their daily nursing activities (see Paper IV). The Finnish data showed that, along with the increase in the patient to RN ratio, the perceived time to perform nursing tasks significantly declined (p<0.001). A significant impact was found in skin care (p<0.001) and patient education (p<0.001). The variation across the countries is illustrated in Paper IV, table 3. 5.4.3 Patient to RN ratios and adverse patient outcomes First, the RNs’ evaluations of the listed adverse patients’ outcomes during the preceding three-month period were investigated (Paper IV, table 4). More than half of the Dutch RNs stated that none of the adverse outcomes listed had occurred during the last three months, and there were statistically significant differences between the countries in this respect. To summarize, patient falls were reported significantly (p=0.006) more frequently by Finnish RNs (56%) and the occurrence of medication errors more frequently by Dutch RNs (48%). Subsequently, the frequency of various adverse outcomes for patients was investigated. The results indicated significant relationships between such outcomes and patient to RN ratio in both countries (see Paper IV, table 5). Although there were many differences, some similarities between the countries were detected. The incidence of patient falls differed significantly (p<0.05) across the three patient to RN intervals (1:4. 1:5-9 and 1:>10) in both countries. While Dutch data indicated a significant relationship between the occurrence of medication errors and patient to RN ratios, this was not confirmed in Finnish data (see Paper IV for details). 34 5.5 SUMMARY OF THE MAIN RESULTS 1) Significant differences in the sample were detected: more male nurses participated from The Netherlands than from Finland or Estonia; the Estonian respondents were most likely to have more than 31 years experience as practicing RNs; Finnish and Estonian participants were overwhelmingly full-time employees and Dutch participants mainly part-time; the average nurse-to-patient ratio was not significantly different between Finland and The Netherlands, but there was a significantly higher nurse-to-patient ratio in Estonia. 2) The most frequently identified RN practice environment characteristic was supportive management. This is obviously one of the most crucial features of practice environment in hospital settings across different health care systems. In addition, teamwork, adequacy of resources and assurance of quality of care were identified as important factors that were common to the different datasets. 3) Participants from Finland were more critical of their practice environment than their colleagues from The Netherlands and Estonia. 4) Comparing Finnish and Dutch nurse staffing patterns (Estonian data were not available): there were fewer RNs and more LPNs on staff in the Dutch hospitals compared with the Finnish ones. RN from both countries considered that, on average, one or two more nurses were needed in their respective units. 5) The adequacy of resources and supportiveness of management were positively correlated with nurse-assessed quality of care and job-related positive feelings, and negatively correlated with intentions to leave a unit, organization or the entire profession for both Finnish and Dutch RNs. 6) In neither Finland nor The Netherlands the adverse incidents affecting RNs were related to their evaluations of the current practice environment. 7) Finnish RNs reported performing non-nursing and administrative activities more frequently than Dutch RNs and reported more dissatisfaction with the availability of support services. 8) Compared with The Netherlands, Finnish RN appear to have higher workloads, experience higher patient-to-nurse ratios and reported the occurrence of adverse patient outcomes more frequently. 9) The incidences of patient falls were related to the patient to nurse ratio in Finnish and Dutch hospitals. 35 6 Discussion The current results provide an insight into nursing practice in the European context; indeed, the ultimate purpose of this study was to examine the professional practice environment of RNs in hospital settings in three European countries. Understanding RNs’ perceptions of their practice environment is crucial as it enables the evaluation of current nursing practice, implementation of change where applicable, and an examination of any changes made. These are important aspects to consider, since there is increasing evidence that associates a favourable practice environment with better outcomes on all levels: patient, nurse and organization. Such an international perspective serves as a knowledge base for development and implementation of future nursing workforce strategies. These strategies can enhance the performance of hospitals which, in turn, has an impact on each country’s organizational outcomes and overall health care. 6.1 REFLECTION ON THE CRUCIAL FINDINGS AND THEIR SIGNIFICANCE 6.1.1 The professional practice environment To gain an understanding of the professional practice environment in which RNs employed by hospitals in Finland, The Netherlands and Estonia practice, the well-known NWI-R measurement tool was utilized. The current results support the multidimensional conceptualization of the practice environment experienced by RNs. There has been criticism in previous literature (Aiken and Poghosyan 2009) that many of the items included in the NWI-R are used to measure practice environment features that are not unit-specific. In the light of the current findings, however, this can be seen as a favourable characteristic of the tool. This is because RN involvement in hospital affairs, quality improvement programmes and the responsiveness of hospital management to nurses’ concerns are all features of a hospital’s practice environment which in turn is influenced by nurse managers at the hospital level. In fact, the findings relating to factor structure described in this study covered both the unit (adequacy of resources, adequate staffing, nursing competence and support for professional development) and hospital level factors (nurse involvement, assurance of quality of care via collaborative relationships and supportive management). Furthermore, such focus on hospital level data allows to gain a generic picture of nurses’ working life in participating countries. Our data shed light on the results of previous studies using the same instrument. The four factor structure presented by Aiken and Patrician (2000) was apparent only among the Estonian participants in the current research. New factor structures were identified (four to five factors) while conducting separate factor analyses based on data (both to the Finnish and Dutch aggregated data and to the aggregated data of all three participating countries). The results were compared using confirmatory factor analysis. Testing the model with factor solution based on aggregated data of all three countries, the findings indicated a moderate model fit while the original four-factor structure of Aiken and Patrician’s (2000) failed to provide a good model fit. The identified factor modules did not include all of the NWI-R theoretically derived subscales (e.g. autonomy, control over practice, organizational support). This finding leads to a discussion of theoretical and measurement implications for further research. Despite some differences in the number of scales, item loadings and naming, some earlier studies (e.g. van Bogaert et al. 2009b, Cummings et al. 2006, McCusker et al. 2004, Tervo-Heikkinen et al. 2008, Slater et al. 2010) shared common elements with the factor 36 structures reported throughout this study. There were clear similarities in factor naming with studies by Tauton et al. 2001, Lake 2002 and McCusker et al. 2004. To summarize, there were three common professional practice environment features identified, reflecting both current and previous findings: resources, leadership and multiprofessional collaboration. Supportive management was overwhelmingly perceived as the key feature of a professional practice environment among participants. Compared to previous studies, some similarities are apparent. Management concerns are expressed in different ways in the literature. For example in the context of nurse manager ability, leadership, support of nurses (Lake 2002, Li et al. 2007, McCusker et al. 2004) or organizational/administrative support (Aiken & Patrician 2000, Bruyneel et al. 2009, Foley et al. 2002, Vahey et al. 2004). Gunnarsdottir and colleagues (2006) referred to unit and hospital level support to cover the same issues. In some studies support is differentiated (e.g. nurse management at the unit level, hospital management and organizational support) specifying whether it concerns the unit or organizational level (van Bogaert et al. 2009a). Teamwork is often referred to in the context of the nurse physician relationship (Choi et al. 2004, Laschinger et al. 2003). This is to be expected, because it is one of subscales of the instrument originally described by Aiken and Patrician (2000). It is noteworthy that this subscale is common to a number of other professional practice environment measurement instruments (e.g. Lake’s PES scale (2002), Erickson and colleagues’ PPE scale (2004), and Kramer and Schamlenberg’s Essentials of Magnetism tool (2004)). The resources scale has been reported slightly differently across studies both using the NWI-R (Bruyneel et al. 2009, Choi et al. 2004, Gunnarsdottir et al. 2006, KanaiPak et al. 2008, Li et al. 2007, McAuliffe et al 2009, McCusker et al. 2004, Roche et al. 2010, Schubert et al. 2008, Slater & McCormack 2007, Slater et al. 2010 Tervo-Heikkinen et al. 2008, Vahey et al. 2004) and other instruments (Kramer and Schamlenberg 2004, Lake 2002). Mainly they reflect the adequacy of staffing and resources. This is a subscale that was not explicitly identified by Aiken and Patrician (2000), although in two of their scales (control over practice and organizational support) the items reflecting staff adequacy (“Enough registered nurses on staff to provide quality patient care” and “Enough staff to get the work done” – present only in the control over practice scale) were included. Current results indicate that the health care system of a country has influence on the outcomes identified. 6.1.2 Practice environment in relation to nurse-reported outcomes The current study identified important characteristics of RNs’ professional practice environment that were associated with nurse-reported outcomes; these were retrieved from the RN data from Finland and The Netherlands. Outcome-related data was not included in the Estonian study. Most of the outcomes measured in this study, (quality of care, intentions related to a nurse’s job), have been recognized in previous research (Aiken et al. 2008, van Bogaert et al. 2009b, Cho et al. 2009, Vahey et al. 2004). Nevertheless, in none of the previous studies have job-related feelings been reported as an outcome in relation to RNs’ perceptions of their practice environment. Adequacy of resources, as a favourable indicator of the practice environment, was positively correlated across all nurse-reported outcomes examined (quality of care provided, intentions to leave, job-related feelings). Supportive management also holds a crucial position with respect to positive nurse outcomes. Nurse involvement was not significantly related to the outcomes studied. In addition to the two practice environment characteristics mentioned above, RNs’ job-related intentions were predicted by support for professional development, nursing competence and adequate staffing. Assurance of quality of care via collaborative relationships was a predictor for providing quality of patient care, in addition to the practice environment characteristics mentioned previously. The influence of work environment characteristics in perceived patient care quality is 37 consistent with the findings of previous Magnet hospital research (Laschinger et al. 2003, Aiken et al. 2002). In brief, the results support previous evidence (e.g. Aiken et al. 2008, Laschinger et al. 2001) that the organizational characteristics of RNs’ professional practice are indicative of structures that support positive job outcomes. Nevertheless, because the current study did not provide evidence about whether the practice environment has a direct or indirect impact on the outcomes studied, this issue needs to be examined in future research. One significant difference compared to previous studies (Aiken et al. 2002, van Bogaert et al. 2009b) is that, in neither of the participating countries, were adverse incidents affecting nurses related to nurses’ evaluations of their current professional practice environment. This finding requires further in-depth investigation. 6.1.3 Nurse staffing and patient outcomes This study provides information on the relationships between the patient to RN ratio and certain adverse patient outcomes. The current results are in line with previous literature (Garrett 2008, Kane et al. 2007, Tervo-Heikkinen et al. 2008, Weissmann et al. 2007). Although our findings did not identify the ideal number of RNs, the findings provide valuable insights into the effects that major changes in nursing staff may have on adverse outcomes for patients. Along with several similarities, the findings also demonstrate substantial differences between the participating countries. The incidence of patient falls is a nurse-sensitive patient outcome, irrespective of the country and its health care practices. Differences between the countries emerged concerning medication errors and hospital infections. It appears that patient to RN ratios affect these outcomes to a certain extent and that they can be classified as country-specific adverse patient outcomes. Some of the variations identified between the participating countries could be due to cultural differences in their health care systems. Differences in the nursing activities reported by the Dutch and Finnish RNs provide clear indications that the context (type of hospital and the countries’ health care system) influences daily nursing practice. 6.2 REFLECTION ON VALIDITY AND RELIABILITY 6.2.1 The NWI-R instrument The validity and reliability of the used NWI-R instrument has been discussed in the Methods chapter and throughout the published papers. This instrument has been used previously in numerous investigations internationally. Nevertheless, some caution was necessary when using it because of the possibility of differences between hospital settings in the participating countries. In order to overcome cultural biases, it was found to be beneficial to perform back- and forward translation with pilot testing and evaluations were conducted throughout the translation process. Serious issues are associated with the stability of the NWI-R theoretically derived factor structure and the overall reliability and validity of this instrument (van Bogaert et al. 2009b, Cummings et al. 2006, Slater et al. 2010). The researchers involved in the current study agree with the suggestion of Slater and his colleagues (2010) that, in the future a renaming of the subscales is required. In addition, there has been much criticism of the NWI-R (e.g. Cummings et al. 2006, Slater & McCormack 2007), questioning whether it really measures the current work environment of nurses, since both nurses’ work and health care practices have changed a great deal since the time the tool was first developed and then revised. The current results support the accuracy of using this tool as a proper measurement of nurses’ practice environment internationally, since it does appear to reflect the reality of current nursing practice. However, the researchers involved in this study acknowledge that the tool does not include information about, and indicators of evidence-based nursing practice. 38 6.2.2 The sample The sample used in this study included RNs working in hospital settings in Finland, Estonia and The Netherlands. According to Burns and Grove (2001), representativeness is poor if the response rate to a questionnaire survey is lower than 50%. In this study, the response rates of the targeted sample varied greatly between the countries. The response rate was highest among Estonian participants, with 57.9%, followed by Finland with 44.9% and lowest among Dutch participants, with only 33.4%. In Finland and The Netherlands a single-round questionnaire survey was carried out, with no reminders. For the Finnish data non-respondents analysis was not performed. The main reasons given for non-participation by Dutch RNs are discussed in the published papers (see Papers II, III, IV). Furthermore, distribution of the questionnaires may have had an effect on the representativeness of the respondents. In all countries the participants were approached via their home addresses with the intention of providing the opportunity to complete questionnaires outside work time. A cover letter accompanied the questionnaire providing information about the study, instructions on completing the questionnaire and providing guarantees of confidentiality. 6.2.3 Data analysis and results In this study nurses self-assessment was used; this can be viewed critically as it may reduce the internal validity of the results through self-reporting bias. However, the anonymous nature of the questionnaire used in this study should have reduced any tendency towards such bias. Nevertheless, there is also a chance that nurses who were interested in the research topics were more willing to participate in the study, and this in turn could have weakened the internal validity of the results (Burns & Grove 2001). 6.2.4 Generalizability of the results External validity addresses the extent to which the results are generally applicable. The results do not represent all RNs working in hospitals in the three countries studied. The study outcomes should, therefore, be viewed as an indication of RNs’ professional practice environment and related issues in the three countries. Nevertheless, these results provide both country-specific and general baseline information. However, the results are likely to be generally applicable to other hospitals in the study countries, as well as to the ones from other European Union member states. Reviews of hospital nurse practice environment issues may benefit from the data obtained in this study. The current findings are valuable at the hospital, as well as the unit, level. One aspect of this study that could be criticized is that nurse-assessments of patient outcomes, specifically adverse events, were used. Nurse-assessed outcomes may be biased as there is an element of subjectivity. This aspect was taken into account when generalizing findings to all hospitals in a country. 6.3 STRENGTHS AND WEAKNESSES The most important strength of this study was the involvement of RN from hospital settings of three European Union member countries: Finland, The Netherlands and Estonia. From the perspective of international cross-cultural nursing research, this study should be considered significant for the advancement of nursing knowledge with respect to the key issues associated with the professional practice environment in hospital settings as perceived by RNs. The use of a previously developed and tested questionnaire is seen as an advantage. Keeping in mind that the translated instrument can be treated as if it is new, the NWI-R tool was considered to be valid and reliable for capturing the key issues in this study context. Since concerns related to RNs’ practice environment are growing, so the data gathered with a single tool can add valuable information to current nursing practice and administration internationally; as possible solution in one country can serve as an 39 example for others. The results provide baseline information which can be utilized in benchmarking. Moreover, this study demonstrates the importance of involving RNs in measuring and reporting care outcomes that accurately reflect trends in nursing practice. Potential weaknesses of the study concern the fact that the data collected from all participating countries was not identical (unified) across all subscales of the instrument. It must be stressed that it was not the intention to provide a full comparison between the three countries, but rather to outline similarities, especially with respect to shortcomings in RNs’ practice environment. Nevertheless, some comparison was possible, although involving limited elements illustrating the situation in Finnish and Dutch hospitals. 6.4 IMPLICATIONS In the light of the current study findings there are many implications worthy of consideration. As international and cross-cultural nursing research is a powerful tool, which can be used to improve clinical nursing practice, education and management, the implications are considered both at the national and international level. The results indicate that more attention needs to be paid to the following aspects, in order to improve nurses’ practice environment and provide safe patient care: 1) Future actions should focus on redesigning RNs’ practice environment to support their efforts to provide comprehensive, professional nursing care and achieve positive nurse outcomes. The features that contribute to a positive practice environment are obviously key factors in achieving high quality patient care and in developing and retaining the workforce. 2) Nurse managers and leaders need to demonstrate increased attentiveness and be alert to the concerns of RNs with respect to their perceptions of practice environment; they need to tackle any shortcomings in a timely manner. Moreover, they need to find usable tools to evaluate and enhance the RN practice environment. 3) The educational preparation of nurses (e.g. curriculum development) could be improved so that nurses are provided with the organizational skills they need to manage in a rapidly changing practice environment and encourage them to take an active role in ensuring patient safety while providing care. 4) Continuous monitoring of RNs’ perceptions of their practice environment should be treated as a tool (e.g. as a barometer of working conditions) for staffing decisions at the hospital level and to guide future federal legislative initiatives both nationally and internationally. 5) The current results provide baseline information which can be utilized in benchmarking, both nationally and internationally. 6) This study has contributed substantially to the knowledge available about RNs’ perceptions about their professional practice environment and the relationships between practice environment and nurse-reported job and patient outcomes in the European hospital context. Moreover, further development and testing of the theoretical module underlying this study is needed based on the new knowledge identified as outcomes of current research. 40 6.5 RECOMMENDATIONS FOR FURTHER RESEARCH Based on the results of this study, there is certainly a need for further research in this area. 1) Further work is required to examine, in detail, the best model (factor structure) for the NWI-R and to determine the optimum structure reflecting RNs’ practice environment in hospitals in European countries. 2) RNs’ practice environment and its relationships with outcomes need to be mapped across a range of units (e.g. medical and surgical, ICU, adult and paediatric) in hospital settings. The findings need to be considered first at the hospital, then at the national level; subsequently, they could be used for benchmarking at levels up to the international context. Thereafter, data reflecting out-patient nursing practices should be considered. 3) More in-depth analysis should examine RNs’ evaluations of their practice environment in relation to adverse incidents affecting nurses. 4) Further studies should investigate whether the relationships between the RN practice environment, nursing activities, nurse staffing and adverse patient outcomes are direct or indirect, and identify the mediating factors involved. 5) Studies with longitudinal designs and alternative data collection methods must be implemented in order to ensure that relevant information is continuous and provides evidence for managers and policy level decision-makers. 6) Similar comparative studies at a larger scale, including more European countries, would be useful. 41 7 Conclusions Based on the results of this study, the following conclusions can be drawn: 1) RNs' evaluations of their practice environment, in three different health care systems, identify positive and challenging features of their everyday practice; these may be specific to an individual country or be international. Certain shortcomings associated with the nurses’ daily practice were common across the participating countries; it is possible, therefore, that some of these issues could be tackled internationally. 2) The practice environment characteristics identified by Finnish and Dutch RNs are key factors associated with producing a positive practice environment with respect to high quality patient care and nurses’ career intentions. 3) The incidence of patient falls is a nurse-sensitive patient outcome, irrespective of the country and its health care practices and there should be a systematic evaluation and reporting system in use. 4) The results provide empirical evidence that adverse patient outcomes are correlated with organizational structure (i.e. nurse staffing patterns). It is imperative that a critical level of RN staffing is maintained: the findings provide valuable insights into the effects that major changes in nurse staffing (e.g. in Finland and The Netherlands) may have on adverse outcomes for patients. Recognizing this association at the administrative and decision-making level could substantially improve nursing-related patient safety. 5) An investment in the nurses’ working environment is challenging, but worthwhile not only for hospital organizations and leaders in the countries examined, but also in other European countries. The majority of the findings identified within this study context are directly applicable to hospital and nurse managers. 42 References Adams A. & Bond S. 2000. Hospital nurses’ job satisfaction, individual and organisational characteristics. Journal of Advanced Nursing 32(3), 536-543. Aiken L., Sloane D., Cimiotti J., Clarke S., Flynn L., Spetz J., Seago J. & Smith H. 2010. 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