Table 3 shows the difference in nurse workloads across hospitals in Europe and the US. In European countries, the average ratio of patients to nurses across hospitals (and across all shifts) ranged from 5.4 in Norway to 13.0 in Germany, and the average ratio of patient to total staff (including professional registered nurses and non-registered nurses) ranged from 3.3 in Norway to 10.5 in Germany. The staffing ratio in the US was lower (and therefore more favourable) than in any of the European countries apart from Norway; this could have been partly due to the inclusion of nurses other than medical-surgical nurses in the US sample.
Table 3 Nurse staffing in 12 European countries and the US. Data are mean (standard deviation) unless stated otherwise
We found that a substantial proportion of nurses in every country reported quality of care deficits, high nurse burnout, job dissatisfaction, and intention to leave their current positions (table 4). Nurses in Greece reported a particularly high level of nurse burnout, dissatisfaction, and intention to leave; nearly half described their wards as providing poor or fair quality of care, and almost one fifth gave their hospitals a poor or failing safety grade. In the Netherlands, nurse burnout, dissatisfaction, and intention to leave were lower than most countries, but these rates still ranged from 10% 19%; furthermore, only 6% of nurses gave their wards a poor or failing safety grade, and 35% rated care on their wards as fair or poor. The percentage of burnt out and dissatisfied nurses in the US was close to the European median, but the percentage of US nurses intending to leave their jobs in the next year was lower than in all European countries.
Table 4 Nurse outcomes in 12 European countries and the US. Data are number of nurses reporting outcome/total number of nurses surveyed, and percentage
Table 5 shows the percentages of patients who gave high overall ratings to their hospital. High ratings ranged from 35% in Spain to close to 60% in the US, Switzerland, Finland, and Ireland. High patient ratings were associated with the propensity to “definitely” recommend the hospital. Variability in what both nurses and patients experienced in hospitals was, in general, even greater within countries than between countries; however, the association between nurse and patient indicators across hospitals were quite similar. The figure shows a scatterplot for each country in which both nurses and patients reported whether they would recommend their hospital. Each point in the scatterplot is a hospital. Although the proportions of nurses and patients who would recommend their hospitals differed within countries, the association depicted—that is, a high agreement between nurses and patients as to which hospitals provided good care—was shown consistently in different countries.
Table 5 Patient outcomes in 12 European countries and the US. Data are number of patients reporting outcome/total number of patients and percentage
Percentages of patients and nurses recommending their hospital
We estimated the effects of nurses’ practice environment and staffing on nurse outcomes and reports of quality and safety (table 6). We used robust logistic regression models to estimate the effects separately without controls, and used fixed within-country slopes across Europe. We also used multivariate models (also with robust standard errors) to estimate the joint influences of staffing and work environments after controlling for differences in nurses’ characteristics across hospitals, differences in structural characteristics of hospitals, and unmeasured differences in outcomes across countries.
Table 6 Effects of nurse staffing and practice environment on nurse outcomes in study countries
In Europe and the US, an improved work environment was associated with pronounced negative effects on every negatively scaled outcome (that is, had a favourable influence), with and without adjusting for nurse, hospital, and country characteristics. After adjusting for hospital and nurse characteristics, nurses in hospitals with better work environments were half as likely to report poor or fair care quality (Europe, adjusted odds ratio 0.56, 95% confidence interval 0.51 to 0.61; US, 0.54, 0.51 to 0.58) and to give their hospitals poor or failing grades on patient safety (0.50, 0.44 to 0.56; 0.55, 0.50 to 0.61).
Each additional patient per nurse increased the odds of nurses reporting poor or fair quality care (Europe, adjusted odds ratio 1.11, 1.07 to 1.15; US, 1.06, 1.03 to 1.10) and poor or failing safety grades (1.10, 1.05 to 1.16; 1.05, 1.00 to 1.10). Nurse outcomes of high burnout, dissatisfaction, and intention to leave had similar associations with effects, and the work environment effect was generally stronger than the specific staffing effect. Among countries at all levels of health expenditure, improved work environments and increased nurse workloads had similar influences (data not shown).
We used robust logistic regression models to allow for the clustering of patients within hospitals and to estimate the separate effects of different nursing factors and characteristics (table 7). We estimated these effects on the odds of patients rating their hospital highly (9 or 10 points v <9 points); patients indicating that they would definitely recommend their hospital; and patients responding that nurses always treated them with courtesy and respect, listened to them carefully, and explained things in a clear manner.
Table 7 Effects of nursing factors and characteristics on patient outcomes in study countries
An improved work environment had a substantially positive effect on all three positively scaled patient measures in all countries (that is, a favourable influence). Patients in hospitals with better work environments were more likely to rate their hospital highly both in Europe (adjusted odds ratio 1.16, 95% confidence interval 1.03 to 1.32) and the US (1.18, 1.13 to 1.23) and to recommend their hospital (Europe, 1.20, 1.05 to 1.37; US, 1.23, 1.17 to 1.29). Patients in hospitals with higher ratios of patients to nurses (that is, increased nurse workload) were less likely to rate their hospital highly (0.94, 0.91 to 0.97; 0.96, 0.94 to 0.98) and to recommend their hospital (0.95, 0.91 to 0.98; 0.95, 0.92 to 0.97). Patients were also less likely to rate their hospital highly, recommend their hospital, and respond favourably about nurses in hospitals with increased percentages of nurses reporting only fair or poor quality care and poor or failing safety grades (table 7). Patients were less satisfied with hospitals that had higher percentages of burnt out or dissatisfied nurses or nurses who lacked confidence in management.