by Peter Griffiths
BMJ, 344. doi: 10.1136/bmj.e1717
authors:
Linda H Aiken
Walter Sermeus
Koen Van den Heede
Douglas M Sloane
Reinhard Busse
Martin McKee
Luk Bruyneel
Anne Marie Rafferty
Peter Griffiths
Maria Teresa Moreno-Casbas
Carol Tishelman
Anne Scott
Tomasz Brzostek
Juha Kinnunen
Rene Schwendimann
Maud Heinen
Dimitris Zikos
Ingeborg Strømseng Sjetne
Herbert L Smith
Ann Kutney-Lee
Objective: Cost containment is exerting pressures on the hospital nurse workforce that may conflict with quality and... more
Objective: Cost containment is exerting pressures on the hospital nurse workforce that may conflict with quality and safety improvement. Europe is an ideal laboratory for determining how to realign organisational behaviors to achieve good patient and workforce outcomes in a context of finite resources.
Design: Cross-sectional surveys of patients and nurses.
Setting: Nurses were surveyed in 488 general acute care hospitals in 12 European countries and 617 general acute care hospitals in the United States. Patients were surveyed in a subset of 210 of the European hospitals and 430 of the United States hospitals.
Participants: 33,659 nurses and 11,318 patients in Europe and 27,509 nurses and over 120,000 patients in the United States.
Measurements: Hospital staffing, nurse work environments, burnout, dissatisfaction, intentions to leave, patient safety, quality of care, patient satisfaction overall and with nursing care and willingness to recommend their hospitals.
Results: The percentage of nurses reporting poor or fair quality of patient care varied substantially by country from 11% (Ireland) to 47% (Greece) as did the percentage that gave their hospital a poor or failing safety grade (4% in Switzerland to 18% in Poland). High nurse burnout ranged from 10% (Netherlands) to 78% (Greece), job dissatisfaction from 11% (Netherlands) to 56% (Greece), and intent to leave from 14% (United States) to 49% (Finland and Greece). Percent of patients rating their hospitals highly varied considerably across countries from 35% (Spain) to 61% (Finland and Ireland), as did the percentage of patients that were willing to recommend their hospital (53% in Greece to 78% in Switzerland). Better work environments and lower patient-to-nurse ratios were associated with higher care quality and higher patient satisfaction. After adjusting for hospital and nurse characteristics, nurses in European hospitals with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval, 0.51 to 0.61) and to give their hospitals poor or failing grades on patient safety (adjusted odds ratio 0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds on nurses reporting poor or fair quality car (adjusted odds ratios 1.11, 1.07 to 1.15) and poor or failing safety grades e (adjusted odds ratio 1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (adjusted odds ratio 1.16, 1.03 to 1.32) and to recommend their hospital (adjusted odds ratio 1.41, 1.22 to 1.62), while patients in hospitals with higher patient-to-nurse ratios were less likely to rate their hospital highly (adjusted odds ratio 0.94, 0.91 to 0.97) or recommend their hospital (adjusted odds ratio 0.95, 0.91 to 0.98). Findings were similar in the United States. Nurses and patients agreed on which hospitals provided good care and could be recommended.
Conclusions: Hospital care quality deficits were common in all countries. Improving hospital work environments may be a relatively low cost lever to produce safer and higher quality hospital care and higher patient satisfaction.
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