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1.  One size does not fit all: a qualitative content analysis of the importance of existing quality improvement capacity in the implementation of Releasing Time to Care: the Productive Ward™ in Saskatchewan, Canada 
Releasing Time to Care: The Productive Ward™ (RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit’s existing QI capacity on their ability to engage with RTC as a program for continuous QI.
We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment.
The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work.
RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0642-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4279911  PMID: 25523134
Productive ward; Releasing time to care; Organizing for quality; Nursing; Qualitative methodology; Quality improvement capacity; Change mechanisms
2.  Assessing the Susceptibility of Transgenic Mice Overexpressing Deer Prion Protein to Bovine Spongiform Encephalopathy 
Journal of Virology  2014;88(3):1830-1833.
Several transgenic mouse models have been developed which facilitate the transmission of chronic wasting disease (CWD) of cervids and allow prion strain discrimination. The present study was designed to assess the susceptibility of the prototypic mouse line, Tg(CerPrP)1536+/−, to bovine spongiform encephalopathy (BSE) prions, which have the ability to overcome species barriers. Tg(CerPrP)1536+/− mice challenged with red deer-adapted BSE resulted in 90% to 100% attack rates, and BSE from cattle failed to transmit, indicating agent adaptation in the deer.
PMCID: PMC3911610  PMID: 24257620
3.  Development of an early nurse led intervention to treat children referred to secondary paediatric care with constipation with or without soiling 
BMC Pediatrics  2013;13:193.
Constipation is a common chronic childhood condition referred to secondary care. Effective treatment requires early intervention, prolonged medication to soften stools and behavioural support to achieve a regular habit of sitting on the toilet to pass a stool. The purpose of this audit and service development was to assess routine consultant paediatrician-led care against minimum standards and if appropriate to develop a nurse-led intervention. The new care package could then be tried out within general paediatric clinics in Glasgow as a service evaluation. NICE guideline (CG99) has a research recommendation to compare nurse-led care with routine consultant-led care.
Design was an audit then development of a nurse-led intervention followed by a service evaluation. Participants were children (age 0–13 years), referred by their General Practitioner (GP) to the Royal Hospital for Sick Children Glasgow, with constipation the main problem in the GP letter. The audit covered appointment waiting times, intervention provided, initial follow-up and parental satisfaction with routine consultant-led practice. The nurse-led intervention focused on self-help psychology practice with NICE guideline medical support. This was compared with routine consultant paediatrician care in a service evaluation.
The audit found consultant-led care had long waiting times, delayed initial follow-up and variable intervention. The new nurse-led intervention is described in detail. The nurse-led intervention performed well compared with consultant-led care. Less ‘nurse-led’ children, 3/45 (7%), were still constipated passing less than 3 stools per week compared with 8/58 (14%) receiving consultant-led care. Less ‘nurse-led’ parents, 10/45 (22%), reported their child having pain passing stools in the previous week compared with consultant-led care, 26/58 (45%). The proportion of children, over 4 years, free from soiling accidents was similar, 15/23 (65%) in the nurse-led group and 18/29 (62%) with consultant-led care. Parental satisfaction was slightly better in the nurse-led group.
It is difficult to achieve minimum standards using routine consultant-led care for children referred by their GP with constipation. Nurse-led early intervention is feasible and has produced promising results in a service evaluation. An exploratory trial is planned to develop a teaching module, robust outcomes including costs and benefits, and methodology for a definitive trial recommended by NICE.
PMCID: PMC3870966  PMID: 24252503
Constipation; Child; Intervention studies; Psychological techniques; Medicine
4.  Atypical Scrapie Prions from Sheep and Lack of Disease in Transgenic Mice Overexpressing Human Prion Protein 
Emerging Infectious Diseases  2013;19(11):1731-1739.
Public and animal health controls to limit human exposure to animal prions are focused on bovine spongiform encephalopathy (BSE), but other prion strains in ruminants may also have zoonotic potential. One example is atypical/Nor98 scrapie, which evaded statutory diagnostic methods worldwide until the early 2000s. To investigate whether sheep infected with scrapie prions could be another source of infection, we inoculated transgenic mice that overexpressed human prion protein with brain tissue from sheep with natural field cases of classical and atypical scrapie, sheep with experimental BSE, and cattle with BSE. We found that these mice were susceptible to BSE prions, but disease did not develop after prolonged postinoculation periods when mice were inoculated with classical or atypical scrapie prions. These data are consistent with the conclusion that prion disease is less likely to develop in humans after exposure to naturally occurring prions of sheep than after exposure to epizootic BSE prions of ruminants.
PMCID: PMC3837652  PMID: 24188521
Atypical scrapie; bovine spongiform encephalopathy; BSE; Nor98 scrapie; prions; prion disease; prion protein; scrapie; sheep BSE; transgenic mice; transmissible spongiform encephalopathy (TSE); variant Creutzfeldt-Jakob disease; vCJD
6.  Acupuncture for ‘frequent attenders’ with medically unexplained symptoms: a randomised controlled trial (CACTUS study) 
The British Journal of General Practice  2011;61(587):e295-e305.
Medically unexplained physical symptoms (MUPS) are common and difficult to treat.
To investigate the effectiveness of adding five-element acupuncture to usual care in ‘frequent attenders’ with MUPS.
Design and setting
Randomised controlled trial in four London general practices.
Participants were 80 adults with MUPS, consulting GPs ≥8 times/year. The intervention was individualised five-element acupuncture, ≥12 sessions, immediately (acupuncture group) and after 26 weeks (control group). The primary outcome was 26-week Measure Yourself Medical Outcome Profile (MYMOP); secondary outcomes were wellbeing (W-BQ12), EQ-5D, and GP consultation rate. Intention-to-treat analysis was used, adjusting for baseline outcomes.
Participants (80% female, mean age 50 years, mixed ethnicity) had high health-resource use. Problems were 59% musculoskeletal; 65% >1 year duration. The 26-week questionnaire response rate was 89%. Compared to baseline, the mean 26-week MYMOP improved by 1.0 (95% confidence interval [CI] = 0.4 to 1.5) in the acupuncture group and 0.6 (95% CI = 0.3 to 0.9) in the control group (adjusted mean difference: acupuncture versus control –0.6 [95% CI = –1.1 to 0] P = 0.05). Other between-group adjusted mean differences were: W-BQ12 4.4 (95% CI = 1.6 to 7.2) P = 0.002; EQ-5D index 0.03 (95% CI = –0.11 to 0.16) P = 0.70; consultation rate ratio 0.90 (95% CI = 0.70 to 1.15) P = 0.4; and number of medications 0.56 (95% CI = 0.47 to 1.6) P = 0.28. All differences favoured the acupuncture group. Imputation for missing values reduced the MYMOP adjusted mean difference to –0.4 (95% CI = –0.9 to 0.1) P = 0.12. Improvements in MYMOP and W-BQ12 were maintained at 52 weeks.
The addition of 12 sessions of five-element acupuncture to usual care resulted in improved health status and wellbeing that was sustained for 12 months.
PMCID: PMC3103692  PMID: 21801508
acupuncture; chronic disease; medically unexplained symptoms; primary care; randomised controlled trial
7.  Traditional acupuncture for people with medically unexplained symptoms: a longitudinal qualitative study of patients’ experiences 
The British Journal of General Practice  2011;61(587):e306-e315.
People with medically unexplained physical symptoms (MUPS) are helped by interventions that combine physical and psychological explanations and treatment. Traditional acupuncture may offer such a perspective, but its use for these patients has not been investigated.
To ascertain how patients with MUPS perceive and experience five-element acupuncture treatment.
Design and setting
A longitudinal qualitative interview study, nested in a randomised controlled trial was carried out in four general practices in socioeconomically diverse areas of London.
A purposive sample of 20 trial participants was interviewed twice, at the start and the end of 6 months of acupuncture treatment. Semi-structured interviews were transcribed, coded, and analysed thematically, summarising both across-case as themes and within-case individual vignettes.
Acupuncture, initially accepted as ‘just another referral’ — one like many others that had been tried and proved unsuccessful — was valued for the amount of time allotted with a caring practitioner who listened and responded, as well as for the interactive and holistic nature of the sessions. These attributes encouraged many patients to take an active role in their treatment, including making cognitive or behavioural lifestyle changes. Interviewees cited a wide range of changes in their health that spanned physical, psychological, and social dimensions. These were largely positive and included an increase in physical and/or mental energy, as well as feelings of greater personal control, calmness, and relaxation. Three interviewees reported worsening health but did not ascribe this to acupuncture.
Many patients who were treated with five-element acupuncture perceived a range of positive effects and appeared to take on a more active role in consultations and self-care.
PMCID: PMC3103693  PMID: 21801509
acupuncture therapy; frequent attenders; patient participation; primary care; qualitative research; unexplained symptoms
8.  Pharmaceutical Nanoparticles and the Mucin Biopolymer Barrier 
BioImpacts : BI  2012;2(4):173-174.
Mucus in the gastrointestinal tract remains a tenacious barrier that restricts the passage of many orally administered compounds into the GIT’s epithelial layer and consequently into the systemic circulation. This results in significant decreases in the oral bioavailability of many therapeutic molecules. Nanoparticles offer an avenue to surpass this mucus barrier. They can be used as drug carriers to improve the bioavailability of many compounds that are restricted by mucus. Nanoparticles achieve penetration of the mucus barrier through a multitude of properties that they possess as their size, charge density, and surface functional groups which can all be tailored to achieve optimal penetration of the thick and fibrous mucus barrier. This article offers a quick review about the use of nanoparticles as drug carriers to increase mucus penetration in the gastro intestinal tract.
PMCID: PMC3648940  PMID: 23678457
Nanoparticles; Mucus; Mucin
9.  Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology 
BMC Nursing  2011;10:6.
Current human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care.
A multi-country, multilevel cross-sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences.
This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce.
RN4CAST is one of the largest nurse workforce studies ever conducted in Europe, will add to accuracy of forecasting models and generate new approaches to more effective management of nursing resources in Europe.
PMCID: PMC3108324  PMID: 21501487
10.  Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected data 
In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.
To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.
Design of the study
Cross-sectional analysis of routine data.
English general practice in 2005/2006.
QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.
A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA1C] ≤7.4%, HbA1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).
Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.
PMCID: PMC2801804  PMID: 20040166
cross-sectional studies; family practice; health care; incentive; nursing staff; personnel staffing and scheduling; physician incentive plans; quality indicators; quality of health care; reimbursement
11.  Hospital admissions for asthma, diabetes and COPD: is there an association with practice nurse staffing? A cross sectional study using routinely collected data 
Delivering good quality primary care for patients with chronic conditions has the potential to reduce non-elective hospital admissions. Practice nurse staffing levels in England have been linked to attainment of general practice performance targets for some chronic conditions. The aim of this study was to examine whether practice nurse staffing level is similarly associated with non-elective hospital admissions in three clinical areas: asthma, Chronic Obstructive Pulmonary Disease (COPD) and diabetes.
This observational study used cross sectional analysis of routinely collected data. Hospital admissions data for the period 2005-2006 (for asthma, COPD and diabetes) were linked with a database of practice characteristics, nurse staffing data and data on population characteristics for the same period. Statistical modelling explored the relationship between non-elective hospital admission rates for the three conditions and the list size per full time equivalent (FTE) practice nurse.
Higher practice nurse staffing levels were significantly associated with lower rates of admission for asthma (p < 0.001) and COPD (p < 0.001). A similar association was seen for patients with two or more admissions (p < 0.05 for asthma and p < 0.001 for COPD). For diabetes, higher practice nurse staffing level was significantly associated with higher admission rates (p < 0.05), but this association was not significant in case of patients with two or more admissions. Across all models, increasing deprivation was associated with higher admission rates for all conditions.
The inconsistent relationship between nurse staffing and patient outcomes across the different conditions and the fact that for diabetes the relationship between staffing and outcomes was in a different direction from the association between staffing and care quality, highlights the need to avoid making a simple causal interpretation of these findings and reduces the possible confidence in such conclusions. There is a need for more research into the organisation and delivery of diabetes care services in general practice, preferably using patient level data; in order to better understand the impact of the different staffing configurations on patient outcomes.
PMCID: PMC2955649  PMID: 20858245
12.  Determinants of knowledge gain in evidence-based medicine short courses: an international assessment 
Open Medicine  2010;4(1):e3-e10.
Health care professionals worldwide attend courses and workshops to learn evidence-based medicine (EBM), but evidence regarding the impact of these educational interventions is conflicting and of low methodologic quality and lacks generalizability. Furthermore, little is known about determinants of success. We sought to measure the effect of EBM short courses and workshops on knowledge and to identify course and learner characteristics associated with knowledge acquisition.
Health care professionals with varying expertise in EBM participated in an international, multicentre before–after study. The intervention consisted of short courses and workshops on EBM offered in diverse settings, formats and intensities. The primary outcome measure was the score on the Berlin Questionnaire, a validated instrument measuring EBM knowledge that the participants completed before and after the course.
A total of 15 centres participated in the study and 420 learners from North America and Europe completed the study. The baseline score across courses was 7.49 points (range 3.97–10.42 points) out of a possible 15 points. The average increase in score was 1.40 points (95% confidence interval 0.48–2.31 points), which corresponded with an effect size of 0.44 standard deviation units. Greater improvement in scores was associated (in order of greatest to least magnitude) with active participation required of the learners, a separate statistics session, fewer topics, less teaching time, fewer learners per tutor, larger overall course size and smaller group size. Clinicians and learners involved in medical publishing improved their score more than other types of learners; administrators and public health professionals improved their score less. Learners who perceived themselves to have an advanced knowledge of EBM and had prior experience as an EBM tutor also showed greater improvement than those who did not.
EBM course organizers who wish to optimize knowledge gain should require learners to actively participate in the course and should consider focusing on a small number of topics, giving particular attention to statistical concepts.
PMCID: PMC3116678  PMID: 21686291
13.  Is satisfaction a direct predictor of nursing turnover? Modelling the relationship between satisfaction, expressed intention and behaviour in a longitudinal cohort study 
The theory of planned behaviour states that attitudinal variables (e.g. job satisfaction) only have an indirect effect on retention whereas intentions have a direct effect. This study uses secondary data from a longitudinal cohort of newly qualified nurses to test for the direct and indirect effects of job satisfaction (client care, staffing, development, relationships, education, work-life interface, resources, pay) and intentions to nurse on working as a nurse during the 3 years after qualification.
A national sample (England) of newly qualified (1997/98) nurses (n = 3669) were surveyed at 6 months, 18 months and 3 years. ANOVA and MANOVA were used for comparison of mean job satisfaction scores between groups; intentions to nurse (very likely, likely vs. unlikely, very unlikely and unable to say at this stage); working (or not working as a nurse) at each time-point. Indirect and direct effects were tested using structural equation and logistic regression models.
Intentions expressed at 6 months to nurse at 18 months were associated with higher scores on pay and relationships, and intentions at 3 years were associated with higher scores on care, development, relationships, work-life interface, resources, pay respectively. Intentions expressed at 18 months to nurse at 3 years were associated with higher scores on development, relationships, education and work-life interface. Associations with actual nursing were fewer. Those working as a nurse had higher satisfaction scores for development (18 months) and relationships (3 years). Regression models found significant associations between the pay and staffing factors and intentions expressed at 6 months to nurse at 18 months, and between pay and intentions to nurse at 3 years. Many of the associations between intentions and working as a nurse were significant. Development was the only job satisfaction factor significantly associated with working as a nurse and just at 18 months.
Results partially support the theory of planned behaviour. Intentions expressed by nurses are stronger predictors of working as a nurse than job satisfaction. Retention strategies should focus on identifying nurses showing early signs of departure with emphasis on developmental aspects, mentoring and support.
PMCID: PMC2600630  PMID: 18976478
14.  A Japanese version of the Perceived Stress Scale: cross-cultural translation and equivalence assessment 
BMC Psychiatry  2008;8:85.
This paper describes the development of a Japanese version of the Perceived Stress Scale (PSS), and examines the equivalence between the original and translated version. The PSS is one of the few instruments to measure a global level of perceived stress, and has been widely used in a range of clinical and research settings. The PSS has already been translated into several languages, but there is no validated Japanese version.
A forward-backward procedure was implemented. Multiple forward and backward translations were produced, and a panel of reviewers verified conceptual and semantic equivalence between the source and final versions. Non-professional translators who were not brought up in bilingual families were used in order to enhance representativeness of language in the target populations. The PSS was administered to 222 native English speakers and the Japanese version (PSS-J) to 1320 native Japanese speakers.
Factor analysis showed similar factor loadings of the items and satisfactory factorial agreement between the PSS and PSS-J. Cronbach's alpha coefficient was high for both versions and for each factor.
It is concluded that the PSS and PSS-J are substantially equivalent and suited for use in comparative cross-cultural studies.
PMCID: PMC2569029  PMID: 18826581
15.  Job satisfaction trends during nurses' early career 
BMC Nursing  2008;7:7.
Job satisfaction is an important component of nurses' lives that can impact on patient safety, productivity and performance, quality of care, retention and turnover, commitment to the organisation and the profession. Little is known about job satisfaction in early career and how it varies for different groups of nurses. This paper investigates how the components of job satisfaction vary during early career in newly qualified UK nurses.
Nurses were sampled using a combined census and multi-stage approach (n = 3962). Data were collected by questionnaire at 6 months, 18 months and 3 years after qualification between 1998 and 2001. Scores were calculated for seven job satisfaction components and a single item that measured satisfaction with pay. Scores were compared longitudinally and between nursing speciality (general, children's, mental health) using a mixed model approach.
No single pattern across time emerged. Trends varied by branch and job satisfaction component. Rank order of job satisfaction components, from high to low scores, was very similar for adult and child branch nurses and different for mental health. Nurses were least satisfied with pay and most satisfied with relationships at 6 and 18 months and with resources (adult and child) and relationships (mental health) at 3 years. Trends were typically upwards for adult branch nurses, varied for children's nurses and downwards for mental health nurses.
The impact of time on job satisfaction in early career is highly dependent on specialism. Different contexts, settings and organisational settings lead to varying experiences. Future research should focus on understanding the relationships between job characteristics and the components of job satisfaction rather than job satisfaction as a unitary construct. Research that further investigates the benefits of a formal one year preceptorship or probationary period is needed.
PMCID: PMC2435528  PMID: 18534023
16.  Translation and equivalence assessment for a Japanese version of the modified Parental Nurturance Scale: a comparative study 
This paper reports on the modification of the Parental Nurturance Scale (PNS), translation of the modified version (PNSM) from English to Japanese, and equivalence assessment between the PNSM and the translated version (PNSM-J). The PNS was modified so as to enable its use in nurturance studies where the prime source of nurturance might vary between respondents.
It was translated into Japanese through the forward-backward translation procedure. With attempting to enhance representativeness of language in the target populations, translators used were married couples that consisted of a native English speaker and a native Japanese speaker. Multiple translations were produced and used to make a single Japanese version. A panel of reviewers identified problems in conceptual and semantic equivalence between the original and the translated versions. The Japanese version was altered accordingly with reference to alternate Japanese forms from the original English to Japanese translations. The altered translation was again re-translated into English and problematic differences were checked. This forward-backward process was repeated until satisfactory agreement was attained. The PNSM was administered to 222 native English speakers and the PNSM-J to 1320 native Japanese speakers.
Factor analysis and target rotation revealed a nearly identical factor structure and factor loadings of the items of the PNSM and PNSM-J between the different cultural groups. High Cronbach's alpha coefficient supported the reliability of the test scores on both versions.
The equivalence between the two scales was supported. It is suggested that the PNSM and PNSM-J are suitable tools for comparative cross-cultural studies.
PMCID: PMC1805774  PMID: 17371574
17.  Nurse led care 
BMJ : British Medical Journal  2005;330(7499):1084.
PMCID: PMC557241
20.  Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States 
Objective To determine whether hospitals with a good organisation of care (such as improved nurse staffing and work environments) can affect patient care and nurse workforce stability in European countries.
Design Cross sectional surveys of patients and nurses.
Setting Nurses were surveyed in general acute care hospitals (488 in 12 European countries; 617 in the United States); patients were surveyed in 210 European hospitals and 430 US hospitals.
Participants 33 659 nurses and 11 318 patients in Europe; 27 509 nurses and more than 120 000 patients in the US.
Main outcome measures Nurse outcomes (hospital staffing, work environments, burnout, dissatisfaction, intention to leave job in the next year, patient safety, quality of care), patient outcomes (satisfaction overall and with nursing care, willingness to recommend 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 rates for nurses who gave their hospital a poor or failing safety grade (4% (Switzerland) to 18% (Poland)). We found high rates of nurse burnout (10% (Netherlands) to 78% (Greece)), job dissatisfaction (11% (Netherlands) to 56% (Greece)), and intention to leave (14% (US) to 49% (Finland, Greece)). Patients’ high ratings of their hospitals also varied considerably (35% (Spain) to 61% (Finland, Ireland)), as did rates of patients willing to recommend their hospital (53% (Greece) to 78% (Switzerland)). Improved work environments and reduced ratios of patients to nurses were associated with increased care quality and patient satisfaction. In European hospitals, after adjusting for hospital and nurse characteristics, nurses 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 give their hospitals poor or failing grades on patient safety (0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds of nurses reporting poor or fair quality care (1.11, 1.07 to 1.15) and poor or failing safety grades (1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (1.16, 1.03 to 1.32) and recommend their hospitals (1.20, 1.05 to 1.37), whereas those with higher ratios of patients to nurses were less likely to rate them highly (0.94, 0.91 to 0.97) or recommend them (0.95, 0.91 to 0.98). Results were similar in the US. Nurses and patients agreed on which hospitals provided good care and could be recommended.
Conclusions Deficits in hospital care quality were common in all countries. Improvement of hospital work environments might be a relatively low cost strategy to improve safety and quality in hospital care and to increase patient satisfaction.
PMCID: PMC3308724  PMID: 22434089
21.  Use of Murine Bioassay to Resolve Ovine Transmissible Spongiform Encephalopathy Cases Showing a Bovine Spongiform Encephalopathy Molecular Profile 
Two cases of unusual transmissible spongiform encephalopathy (TSE) were diagnosed on the same farm in ARQ/ARQ PrP sheep showing attributes of both bovine spongiform encephalopathy (BSE) and scrapie. These cases, UK-1 and UK-2, were investigated further by transmissions to wild-type and ovine transgenic mice. Lesion profiles (LP) on primary isolation and subpassage, incubation period (IP) of disease, PrPSc immunohistochemical (IHC) deposition pattern and Western blot profiles were used to characterize the prions causing disease in these sheep. Results showed that both cases were compatible with scrapie. The presence of BSE was contraindicated by the following: LP on primary isolation in RIII and/or MR (modified RIII) mice; IP and LP after serial passage in wild-type mice; PrPSc deposition pattern in wild-type mice; and IP and Western blot data in transgenic mice. Furthermore, immunohistochemistry (IHC) revealed that each case generated two distinct PrPSc deposition patterns in both wild-type and transgenic mice, suggesting that two scrapie strains coexisted in the ovine hosts. Critically, these data confirmed the original differential IHC categorization that these UK-1 and UK-2 cases were not compatible with BSE.
PMCID: PMC3505794  PMID: 21919992
BSE; mouse bioassay; prion; scrapie; transmissible spongiform encephalopathy
22.  ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care 
BMJ Quality & Safety  2013;23(2):116-125.
There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure—‘missed care’.
To examine the nature and prevalence of care left undone by nurses in English National Health Service hospitals and to assess whether the number of missed care episodes is associated with nurse staffing levels and nurse ratings of the quality of nursing care and patient safety environment.
Cross-sectional survey of 2917 registered nurses working in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England.
Most nurses (86%) reported that one or more care activity had been left undone due to lack of time on their last shift. Most frequently left undone were: comforting or talking with patients (66%), educating patients (52%) and developing/updating nursing care plans (47%). The number of patients per registered nurse was significantly associated with the incidence of ‘missed care’ (p<0.001). A mean of 7.8 activities per shift were left undone on wards that are rated as ‘failing’ on patient safety, compared with 2.4 where patient safety was rated as ‘excellent’ (p <0. 001).
Nurses working in English hospitals report that care is frequently left undone. Care not being delivered may be the reason low nurse staffing levels adversely affects quality and safety. Hospitals could use a nurse-rated assessment of ‘missed care’ as an early warning measure to identify wards with inadequate nurse staffing.
PMCID: PMC3913111  PMID: 23898215
Nurses; Patient safety; Risk management; Health policy
23.  Nurses’ Shift Length and Overtime Working in 12 European Countries 
Medical Care  2014;52(11):975-981.
Despite concerns as to whether nurses can perform reliably and effectively when working longer shifts, a pattern of two 12- to 13-hour shifts per day is becoming common in many hospitals to reduce shift to shift handovers, staffing overlap, and hence costs.
To describe shift patterns of European nurses and investigate whether shift length and working beyond contracted hours (overtime) is associated with nurse-reported care quality, safety, and care left undone.
Cross-sectional survey of 31,627 registered nurses in general medical/surgical units within 488 hospitals across 12 European countries.
A total of 50% of nurses worked shifts of ≤8 hours, but 15% worked ≥12 hours. Typical shift length varied between countries and within some countries. Nurses working for ≥12 hours were more likely to report poor or failing patient safety [odds ratio (OR)=1.41; 95% confidence interval (CI), 1.13–1.76], poor/fair quality of care (OR=1.30; 95% CI, 1.10–1.53), and more care activities left undone (RR=1.13; 95% CI, 1.09–1.16). Working overtime was also associated with reports of poor or failing patient safety (OR=1.67; 95% CI, 1.51–1.86), poor/fair quality of care (OR=1.32; 95% CI, 1.23–1.42), and more care left undone (RR=1.29; 95% CI, 1.27–1.31).
European registered nurses working shifts of ≥12 hours and those working overtime report lower quality and safety and more care left undone. Policies to adopt a 12-hour nursing shift pattern should proceed with caution. Use of overtime working to mitigate staffing shortages or increase flexibility may also incur additional risk to quality.
PMCID: PMC4196798  PMID: 25226543
shift work; quality; safety; nurses; workforce; efficiency; Europe

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