Table shows the numbers of hospitals and nurses in each of the different countries in the study, as well as the average number of nurses per hospital. There were decidedly larger samples of hospitals in the USA (n = 762) and Canada (n = 293) than in the other countries, where the samples of hospitals ranged from 19 (in Japan) to 121 (in China). The mean number of nurse respondents in the study hospitals was substantial, ranging from 51 nurses per hospital in the USA to 313 nurses per hospital in Japan.
Numbers of hospitals and nurses in the study, by country
Table displays the characteristics and outcomes of the surveyed nurses. Most nurses in all countries were staff nurses (as opposed to nurses in managerial positions). The percentages of nurses who were university graduates ranged from 11% in the UK to 88% in Thailand, while the percentage of nurses who were employed part time was nil in China but >50% in the USA, New Zealand and Canada. Nurses in non-permanent positions were relatively rare in most countries. China is an exception where more than half of all hospital nurses did not have permanent positions, but non-permanent nurses are generally indistinguishable from permanent nurses in that country except for contract details. The percentage of nurses that were male was higher in Germany (15%) and lower in China (1%) than in the other countries, and the average years of experience was highest in Canada (18 years) and lowest in South Korea (6 years).
Nurse characteristics and reports of job satisfaction and quality of care in nine countries
The bottom four rows of Table compare nurse-reported outcomes across the nine countries. The percentage of nurses reporting high burnout was over a third in most countries and decidedly higher in South Korea and Japan (near 60% in both countries) than elsewhere. Germany was an outlier with only 15% of nurses reporting high burnout. Job dissatisfaction varied from 17% in Germany to around a third of nurses in most countries and a high of 60% dissatisfied in Japan. Almost half of nurses in all countries, except in Germany, and many more than half of the nurses in a few of the countries, lacked confidence that patients could manage their care after discharge. South Korean and Japanese nurses were more likely than other nurses to report that the quality of patient care on their unit was only fair or poor (as opposed to good or excellent). Unit quality was judged to be fair or poor by only 11% of nurses in Canada compared with a high of 60 and 65% in Japan and South Korea, respectively.
While the variability in these nurse outcomes and nurse assessments of quality of patient care across countries is notable, what is of most interest is how much these outcomes and assessments vary across hospitals within countries, and whether and to what extent the variability is a function of differences across hospitals in terms of their work environment. Table shows that each of the patient care environment scales ranges considerably across hospitals in each country, and the average values range considerably across countries as well. Moreover, Table provides indirect evidence that these different subscales are related in each country, since the percentage of hospitals that are above average on at least 4 of the 5 subscales (i.e. the ‘better’ hospitals) or below average on at least 4 of the 5 subscales, i.e. the ‘poor’ hospitals) both exceed the percentage we would expect (18.75%) if the subscale scores were independent of one another across hospitals in each country. That is, if the different subscales were independent of one another (and given that half the hospitals are above average on each subscale), we would expect 1 out of every 32 hospitals to be above average on all 5 subscales, we would expect 5 in 32 to be above average on 4 of the 5, and 5 + 1 = 6 in 32 (or 18.75%) to be above average on at least 4 of the 5 subscales. And we would expect the same percentage to be below average on at least 4 of the 5 subscales. Notably, between one-quarter and one-third of hospitals in each country were judged to have poor work environments, with China having 44% of its hospitals scoring in the poor category, and similarly high percentages were found to have better work environments. Furthermore, as Table shows, in all countries hospitals with ‘better’ work environments tend, in most cases, to have smaller percentages of nurses reporting negative outcomes (high nurse burnout, job dissatisfaction, not confident patients are prepared for discharge, quality-of-care rated fair or poor) than hospitals with ‘mixed’ work environments, that in turn tend to have smaller percentages of nurses reporting negative outcomes than hospitals with ‘poor’ work environments. While the percentage of nurses reporting negative outcomes does not decline monotonically for all outcomes in every country, some of the departures in the observed percentages from what we would expect may be due to the fact that these percentages reflect gross or unadjusted differences that do not take account of differences across hospitals with better and poorer environments in the characteristics of the nurses reporting the outcomes.
Distributions of work environments for 1406 hospitals in 9 countries
Percentages of nurses reporting negative outcomes and poor quality of care by quality of work environments in hospitals and country (N = 98 116 nurses in 1406 hospitals)
Table takes these analyses a step further by presenting the results of logistic regression models, fitted separately to the data for each country, which estimate the effect of the nurse work environment on the odds of nurses reporting the four negative outcomes, after controlling for differences across hospitals in nurse characteristics that might affect reporting [i.e. nurse specialty, staff nurse designation, nursing education, years of experience in nursing, part-time status, non-permanent status (except in Japan) and gender] and after adjusting for the clustering of nurses within hospitals. In these models, we treat the three-category work environments variable as ordered and linear in its effect, so the estimated odds ratios reflecting the difference between hospitals with ‘mixed’ vs. ‘poor’ environments are the same as that of the difference between hospitals with ‘better’ vs. ‘mixed’ environments, and the estimated odds ratio indicating the difference between ‘better’ vs. ‘poor’ hospitals is equal to that associated with the difference between ‘better’ vs. ‘mixed’ hospitals squared.
Odds ratios indicating the differences in nurses reporting negative job outcomes and poor quality of care across hospitals with mixed vs. poor work environments and better vs. poor work environments, in nine countries
Employment in a hospital with a better work environment (as opposed to a poor one) was associated with decreases in the odds of reporting high burnout across the nine countries, by factors ranging from 0.54 to 0.94, and in all but two cases these associations were statistically significant at the P < 0.05 level. Employment in a hospital with a better work environment as opposed to a poor one was also associated with significant decreases in the odds of reporting job dissatisfaction in eight of the nine countries (all but Thailand), by factors ranging from 0.33 to 0.72, though in Japan the decrease was only marginally significant (or significant at the 0.10 level). Better work environments were also associated with decreases in reports of little or no confidence in discharge readiness and poor or fair quality of care in all countries, and these differences too were significant, or very nearly so, in virtually all countries. The few instances in which significant results were not obtained involved countries with smaller numbers of hospitals, and all results, except in Japan where no effect of the work environment on job dissatisfaction was found, were in the expected direction. While in general the effects of the work environment on the outcomes appear somewhat less pronounced in Thailand and Japan than elsewhere, which might suggest a cultural difference in the effect of this nursing factor, or in its measurement, it does not appear to be pervasive across the Asian countries. On some of these outcomes, the effect of the work environment is as pronounced in South Korea and China as in the non-Asian countries, and sometimes more pronounced.