Shift change handovers and subsequent interruptions: potential impacts on quality of care.

OBJECTIVES: Two statistical surveys in France revealed both widespread dissatisfaction about shift change handovers and the feeling of being frequently disturbed by interruptions. Shift change handovers (SCHs) are being reduced or eliminated in France to reduce staff costs. The objective of our study is to clarify the consequences of short SCHs on efficiency, team function, and quality of care. METHODS: Real-time task ergonomic analysis of 29 state-registered nurses (RNs), 18 nursing aides (NAs), and 14 full-time physicians was conducted in various departments of general and university hospitals. RESULTS: The average time available to RNs for sharing information during SCHs was 15 minutes at the beginning of the work session and 13 minutes at the end. There were, on average, 50 interruptions of activity, and these interruptions occupied 16% of the working time. Consequently, less time was available for direct care, although the number of such acts was increased. Periods for preparation of care, writing, seeking information, or equipment were very numerous. The mean number of changes of activity was very large: 260 per work session. For NAs, SCHs were similar to those for RNs at the beginning of the work session (mean = 18 minutes) but shorter at the end (10 minutes). The mean number of interruptions was 30 and caused 10.3% of the working time to be lost with 164 changes of activity. For physicians, SCHs were even shorter and, in many cases, nonexistent. The mean number of interruptions was 30 (11.4% of their working time, 153 changes of activity). Shift change handovers were mostly conducted separately for RNs, NAs, and physicians. DISCUSSION: A better sharing of knowledge between the different health-care workers, and especially at the beginning of the work session, could reduce interruptions and potentially improve quality of care.

[Sick leave during pregnancy: an analysis of French hospitals from 2005 until 2008 demonstrates the major importance for jobs with physical demands]. / Les arrêts maladie ordinaire pendant la grossesse :une analyse à l'AP-hP de 2005 à 2008 montre leur importance majeure pour les métiers pénibles.

INTRODUCTION: sick-leave in the course of pregnancy play a role under estimated according to several studies.They bring to light the existence of risk factors concerning the physical load for contractions, sick-leave, hospitalizations and prematurity.The data obtained on the totality of the wage earners of the AP-HP allow to avoid all the possible bias and to determine the potential impact of a policy of reduction of the physical load METHOD: The data of four years could be analyzed.The used database is PILOT RH, intranet application restoring information extracted from GIPSIE who was until 2008 the institutional software of management of the careers of all the workers of the AP-HP. RESULTS: In 2008,3 937 women having had a maternity leave (ML) accumulated 132 360 days of ordinary sick-leave (OL) (that is 33,6 days on average) without inclusion of the 15 days accepted for "pathological pregnancy" (PP) and "post pregnancy leave". Ordinary sick-leave of all the 53 132 women amounts to 11.5 days by agent. But, the set apart of the women having had a ML reduces the number of days of sick-leave to 9,7 days This difference weighs for 15.6 % of the total of the absenteeism OL. The results are similar on the four years. The analysis by occupational catégory, for 2008, shows that the average number of days of sick-leave, after exclusion of women having had a ML, decreases with the physical load of the posts estimated by the study PRESST-NEXT :ancillary staff 19.9 days, nursing aids 13.7 days, registered nurses 8.2 days, specialized nurses 7.7 days, medico - technical workers 5.7 days and head nurses 5.1 days. For the women having had a ML, the average number of days of ordinary sick-leave, is the most raised for nursing aids (41.9 days) followed by the ancillary staff (36 days) and the registered nurses (36 days) and slightly less for the specialized nurses (28.3 days). On the other hand, in the professions having least physical load the women have less than 25 days of ordinary sick-leave the year of their pregnancy :medico-technical workers 21.3 days, head nurses 23.1 days and administration staff 23.7 days.The results are similar on the four years. For the nurses, it is 25.5% of total ordinary sick-leave that are attributable to the women having had a pregnancy, and 34.4 % if we add OL and 15 days of official "pathological pregnancy". DISCUSSION: An intervention to reduce the physical load in test hospitals could be led.The reduction of sick-leave in the course of pregnancy can be a fast indicator of evaluation of the efficiency of the investments. The improvements will benefit to all the agents, in the medium term, with a reduction of the risks of musculoskeletal disorders. Such an action also allows to maintain the employability of the older employees and to integrate) persons into situation of handicap in a work which has for them a strong sense and which they do not want to give up.

Effects of extended work shifts on employee fatigue, health, satisfaction, work/family balance, and patient safety.

12-hour shifts are quickly spreading in Europe. From our multivariate analysis concerning 25,924 European nurses, including twenty explanatory variables simultaneously, we found that work schedule itself is not a major determinant factor. Nurses aim to choose or accept night shifts or 12-hour shift in order to reduce their work/home conflicts, however, at the expense of the patient's safety, as well as their own health and safety. Therefore, it is important to develop measures, such as extended child care, association of nurses to the elaboration of their rota, 9- or 10-hour shifts in the afternoon, allowing naps during night shifts, and reduction of changing shifts with short notice. Work schedules must be organized in order to allow time for shift handover, social support and team building.

[Survey on the satisfaction regarding their studies and the health habits of nursing students in France]. / Enquête sur le vécu et les comportements de santé des etudiants en soins infirmiers.

The French Federation of Nursing Student (FNESI) conducted a study in nursing studies institutions from 6 administrative Regions in order to understand risk factors linked with stress or satisfaction of students. Conducted from september 2008 to june 2009, the response rate was 71.2%. Bivariate analysis were conducted on a sample selected by random of 1450 students, to determine potentials risk factors linked with poorer estimated general health and stress. Students declare more and more frequently stress or poor general health in second and third year of nursing studies. Their life habits are inadequate and do not improve when their knowledge increases: lack of sport practice, tobacco smoke, alcohol consumption, other addictive substances ... Among students who declare a too much supported rhythm of training or a poor quality of training, the majority qualify their health of bad. Practical training is considered by a quarter of first year student and 44% of second and third year students. Existence of "speech groups" and free discussion groups have a major influence on satisfaction or stress and poor general health declaration. This study demonstrated the major influence of good mentorship quality by trained nurses and that this nurse in a tutorial position has to be the same all along the training in each department. These aspects have to be improved in order to attract and retain motivated students.

[Participative ergonomics for adapting the working space to meet the needs of nursing staff]. / L'ergonomie participative pour adapter l'espace de travail aux besoins des soignants.

Presst-Next, the European study carried out between 2004 and 2006, highlighted the importance of teamwork in reducing the frequency of professional exhaustion and the early departure of care staff. On the basis of these results, the Armand-Trousseau Hospital in Paris (AP-HP 75) has committed to a participative ergonomics approach at its paediatric emergency service.

Longitudinal analysis of personal and work-related factors associated with turnover among nurses.

BACKGROUND: Although many scholars have acknowledged the relationship between personal and work-related factors associated with job search and actual turnover, there is a lack of longitudinal designs that test this relationship empirically. OBJECTIVES: This longitudinal study examines specific determinant factors that differentiate between so-called "stayers" and "leavers" within the nursing profession and identifies risk factors for premature leaving by comparing nurses who have left their job or the nursing profession with nurses who stay. METHODS: This cross-national exploratory European survey included 34,587 nurses (baseline measurement) working in 623 hospitals, nursing homes, and home care institutions and was composed of two measurements with a 1-year time interval. The final samples for the follow-up measurement included 14,016 stayers and 866 leavers. As regards the leavers, the participating nurses were asked to indicate to what extent personal and work-related factors had contributed to the decision to leave their healthcare institution. RESULTS: Nurses' intent-to-leave scores were higher in the baseline measurement among those who left the organization during the following 12 months than those among nurses who stayed (24.0% vs. 13.5%). A majority of nurses (86.8%) left their profession voluntarily. Involuntary departure occurred more often in Eastern European countries. Nurses indicated that the reasons for leaving were (a) working conditions (e.g., relationship problems, emotional difficulties, time pressure and quality of care, dissatisfaction with use of one's competence and lack of autonomy, work schedule difficulties, and dissatisfaction with pay) and (b) family reasons (e.g., caring for relatives). For a considerable number of nurses, health reasons and the desire for continuing education added to their decision to leave. DISCUSSION: Healthcare organizations should pay attention to preventive measures to protect labor market potential. Recommendations are made for human resource development in healthcare organizations and for further empirical research to better understand to what extent different policy systems across the European countries explain variance in outcomes.

Factors affecting work ability in day and shift-working nurses.

Satisfactory work ability is sustained and promoted by good physical and mental health and by favorable working conditions. This study examined whether favorable and rewarding work-related factors increased the work ability among European nurses. The study sample was drawn from the Nurses' Early Exit Study and consisted of 7,516 nursing staff from seven European countries working in state-owned and private hospitals. In all, 10.8% were day, 4.2% were permanent night, 20.9% were shift without night shift, and 64.1% were shift workers with night shifts. Participants were administered a composite questionnaire at baseline (Time 0) and 1 yr later (Time 1). The Work Ability Index (WAI) at Time 1 was used as the outcome measure, while work schedule, sleep, rewards (esteem and career), satisfaction with pay, work involvement and motivation, and satisfaction with working hours at Time 0 were included as potential determinants of work ability. Univariate and multivariate analyses were conducted after adjusting for a number of confounders (i.e., country, age, sex, type of employment, family status, and other job opportunities in the same area). Work schedule was not related to Time 1 changes in WAI. Higher sleep quality and quantity and more favorable psychosocial factors significantly increased work ability levels. Higher sleep quality and quantity did not mediate the effect of work schedule on work ability. No relevant interaction effects on work ability were observed between work schedule and the other factors considered at Time 0. As a whole, sleep and satisfaction with working time were gradually reduced from day work to permanent night work. However, scores on work involvement, motivation, and satisfaction with pay and rewards were the highest in permanent night workers and the lowest in rotating shift workers that included night shifts.

Age-dependent relationships between work ability, thinking of quitting the job, and actual leaving among Italian nurses: a longitudinal study.

BACKGROUND: Qualified nurses commonly report several work-related problems, which may threat their health and work ability, and may have an impact upon retention. OBJECTIVE: The aim of the present study was to investigate whether perceived work ability is a predictor for different types of thinking of quitting and for actual exit from the workplace. DESIGN: A prospective study has been performed based on 3329 Italian registered nurses which responded to both measurements of the Nurses' Early Exit Study. Institutions were selected by means of a stratified sampling procedure. All the 7447 nurses working in that healthcare organizations were recruited for the study. Baseline questionnaire was collected from 5504 nurses. Response rate at follow-up was 63.4%. Two hundred and fifty-five nurses left the job in the course of the investigation. METHODS: Several multiple logistic regression analyses were performed controlling for indicators of work-related well-being, socio-demographic, and labour-market characteristics. RESULTS: As a whole, our results show that among nurses younger than 45 years work ability is a significant predictor of different types of thinking of quitting, but not of actual exit from the workplace: a lower perceived work ability was associated with a higher desire to undertake further education (OR: 3.05; 95% CI: 1.30-7.18) and/or to change workplace (OR: 4.03; 95% CI: 1.84-8.83) or profession (OR: 6.67; 95% CI: 2.78-15.99). In contrast, among the older nurses (>45), only actual exit was predicted by lower work ability scores (OR: 7.14; 95% CI: 1.15-44.13), along with the perception of a larger availability of free nursing posts in the region (OR: 2.70; 95% CI: 1.13-6.43). CONCLUSION: Therefore, we conclude that in the relationship between low perceived work ability and intended or actual exit, a significant part is explained by age itself, but also by the age-related differences in occupational and life opportunities. This contribution concludes with some age-related policies aimed at boosting nurses' retention.

Violence risks in nursing--results from the European 'NEXT' Study.

BACKGROUND: Recent research suggests that violence in health care is increasing and that it strongly influences the recruitment and retention of nurses as well as sick leave and burnout levels. AIMS: To identify the prevalence of violence in nursing and to provide a basis for appropriate interventions. METHODS: Nurses from 10 European countries answered to a questionnaire and to a follow-up assessment. Stepwise adjusted multiple logistic regression was used to assess the association between frequency of violence, factors related to teamwork and other work-related factors and outcomes, such as burnout, intention to leave nursing and intention to change institution. RESULTS: A total of 39,894 nurses responded to the baseline questionnaire (51% response rate). After adjustment for age, gender and other risk factors, quality of teamwork appeared to be a major factor with odds ratio (OR) 1.35 (1.24-1.48) for medium quality and 1.52 (1.33-1.74) for low quality. Uncertainty regarding patients' treatments was linked with violence, with a clear gradient (OR 1.59, 1.47-1.72 for medium uncertainty and 2.13, 1.88-2.41 for high uncertainty). Working only night shift was at high risk (OR 2.17, 1.76-2.67). High levels of time pressure and physical load were associated with violence OR 1.45 (1.24-1.69) and 1.84 (1.66-2.04), respectively. High and medium frequency of violence was associated with higher levels of burnout, intent to leave nursing and intent to change institution. A 1-year follow-up assessment indicated stability in the relationships between outcomes. CONCLUSION: This study supports efforts aimed at improving teamwork-related factors as they are associated with a decrease in violence against nurses.

Back or neck-pain-related disability of nursing staff in hospitals, nursing homes and home care in seven countries--results from the European NEXT-Study.

BACKGROUND: Musculoskeletal disorders are a widespread affliction in the nursing profession. Back or neck-pain-related disability of nursing staff is mainly attributed to physical and psychosocial risk factors. OBJECTIVES: To investigate which-and to what extent-physical and psychosocial risk factors are associated with neck/back-pain-related disability in nursing, and to assess the role of the type of health care institution (hospitals, nursing homes and home care institutions) within different countries in this problem. DESIGN: Cross-sectional secondary analysis of multinational data of nurses and auxiliary staff in hospitals (n=16,770), nursing homes (n=2140) and home care institutions (n=2606) in seven countries from the European NEXT-Study. METHODS: Multinomial logistic regression analysis with raw models for each factor and mutually adjusted with all analysed variables. RESULTS: Analysis of the pooled data revealed effort-reward imbalance as the predominant risk factor for disability in all settings (odds ratios for high disability by effort-reward ratio: hospital 5.05 [4.30-5.93]; nursing home 6.52 [4.04-10.52] and home care 6.4 [3.83-10.70] [after mutual adjustment of psychosocial and physical risk factors]). In contrast, physical exposure to lifting and bending showed only limited associations with odds ratios below 1.6; the availability and use of lifting aids was-after mutual adjustment-not or only marginally associated with disability. These findings were basically confirmed in separate analyses for all seven countries and types of institutions. CONCLUSIONS: The findings show a pronounced association between psychosocial factors and back or neck-pain-related disability. Further research should consider psychosocial factors and should take the setting where nurses work into account.

Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study.

BACKGROUND: The occurrence of workplace violence is rather frequent within the nursing profession, with well-known consequences on the psychological health of victims. OBJECTIVES: This study is aimed at assessing the relationships between relevant individual, organizational, and psychosocial factors, and the frequency of several types of workplace violence; the direct as well as the interactive impact of violence and psychosocial factors on organizational commitment and perceived health. DESIGN: Questionnaire-based cross-sectional and longitudinal survey designs were employed for the two study objectives, respectively. SETTING: Five hundred and sixty-five healthcare institutions from eight European countries participated in the Nurses' Early Exit Study. PARTICIPANTS: The 34,107 participants were nursing staff holding different qualifications. The response rate was 55.1% in the cross-sectional part and 40.5% in the follow-up phase. At baseline, the respondents were mostly female (89.3%), in the age group 30-44 years (52.9%), registered or specialized nurses (67.0%), working mainly in medico-surgical wards (36.3%), and employed full-time (72.8%). METHODS: In the cross-sectional analysis, the relationship between the predictor variables and frequency of violence was assessed by means of a hierarchical multiple linear regression. In the longitudinal analysis, main direct and interactive effects of violence and psychosocial factors on perceived health and organizational commitment were assessed by means of hierarchical multiple linear regression analyses with interaction terms. RESULTS: Higher levels of adverse work-related factors were significantly associated with higher frequency of the distinguished types of violence. Significant interactions were found between psychosocial factors and violence only in predicting organizational commitment, even if effect sizes were very low. No interactions were observed for perceived health. The prevalence of the distinguished types of violence varied across the participating countries according to the presence of adverse work- and non-work-related factors. CONCLUSIONS: These findings suggest the necessity of interventions both over working conditions conducive to violence and violent behaviours themselves.

The impact of social work environment, teamwork characteristics, burnout, and personal factors upon intent to leave among European nurses.

OBJECTIVES: Europe's nursing shortage calls for more effective ways to recruit and retain nurses. This contribution aims to clarify whether and how social work environment, teamwork characteristics, burnout, and personal factors are associated with nurses' intent to leave (ITL). METHODS: Our sample comprises 28,561 hospital-based nurses from 10 European countries. Different occupational levels have been taken into account: qualified registered nurses (n = 18,594), specialized nurses (n = 3957), head nurses (n = 3256), and nursing aides and ancillary staff (n = 2754). RESULTS: Our outcomes indicate that ITL is quite prevalent across Europe, although we have found some differences across the countries depending on working conditions and economic situation. Quality of teamwork, interpersonal relationships, career development possibilities, uncertainty regarding treatment, and influence at work are associated with nurses' decision to leave the profession across Europe, notwithstanding some country-specific outcomes. A serious lack of quality of teamwork seems to be associated with a 5-fold risk of ITL in 7 countries. As far as personal factors are concerned, our data support the hypothesized importance of work-family conflicts, satisfaction with pay, and burnout. A high burnout score seems to be associated with 3 times the risk of ITL in 5 countries. CONCLUSIONS: To prevent premature leaving, it is important to expand nurses' expertise, to improve working processes through collaboration and multidisciplinary teamwork, and to develop team training approaches and ward design facilitating teamwork.

Nurses' perception of shift handovers in Europe: results from the European Nurses' Early Exit Study.

AIM: This paper reports a study exploring nurses' perceptions of the shift handover and the possible reasons for reported dissatisfaction in 10 European countries. BACKGROUND: The nursing handover fulfils a number of purposes and has important consequences for the continuity of patient care and nurses' satisfaction with the quality of care they are able to provide. However, the performance and function of shift handovers in health care is a widely neglected topic in practice and research. METHOD: The Nurses' Early Exit Study (http://www.next-study.net) investigates the working conditions of nurses and variables influencing nursing retention. The data for this analysis were collected between 2002 and 2003 by self-report questionnaires in 10 European countries. FINDINGS: The percentage of nurses dissatisfied with shift handovers ranged from 22% in England to 61% in France. In most countries the main reason for dissatisfaction with shift handovers was 'too many disturbances', followed by 'lack of time'. Most countries showed similar associations of dissatisfaction with qualification level and occupational seniority, but not with position and type of shift. 'Poor quality of leadership' and 'poor support from colleagues', were strongly associated with dissatisfaction. CONCLUSIONS: In several (but not all) European countries, shift handovers may be a frequent cause for nurses' irritation. The underlying causes appear to be of an organizational nature. The findings have implications for solutions. Further debate and research should clarify the different purposes of shift handovers and relate them to handover style and to the quality of patient care.

[Factors associated with violence against healthcare workers: results of the European Presst-Next study]. / Facteurs liés aux épisodes violents dans les soins: résultats de l'enquête européenne Presst-Next.

INTRODUCTION: The respective roles of medical specialties and work organization on violent events against healthcare workers (HCW) in different countries was examined. METHODS: Using the results of the Presst-Next study, we analyzed data from 27134 HCW in 7 European countries. Multivariate logistic analyses were conducted with SPSS 12 software. RESULTS: After adjustment for age, gender and other occupational risk factors, the factors indicating insufficient team work were highly associated with an increased risk of violent events. Dissatisfaction with shift change (OR=1.35; 95%CI 1.23-1.47), uncertainty about treatment (OR=1.57; 95%CI 1 .44-1.71), and frequent interruptions (OR=2.04; 95%CI 1.81-2.31) were linked to violent events, up to twice the number among HCW reporting better team work. Contradictory orders, dissatisfaction with psychological support, and harassment by superiors were all significantly associated with increased reporting of frequent violent events. We observed a positive gradient between violent events and job demand (time pressure) (OR=1.25 for an intermediate score and OR=1.55 for a high score, compared with a low score). Loneliness at work, certain work schedules, and physical load increased the risk. Nurses' aides were exposed to violent events more often (OR=1.57; 95%CI 1.38-1.79) than head nurses. Older HCW and those with more experience were less exposed. The highest risks were associated with working in psychiatric (OR=4.89; 95%CI 3.82-6.25) and emergency (OR=2.68; 95%CI 2.10-3.44) departments, compared with home care and day care. The excess risk was an additional 30% in geriatrics and long-stay departments. Significantly less risk was observed in pediatrics, obstetrics and gynecology departments (OR=0.70; 95%CI 0.56-0.88). CONCLUSION: Team building requires time, and shift change is a key period. This time is far from nonproductive. Rather, its effective use reduces treatment errors, enhances quality of care, and reduces the frequency of violent events. It is crucial in every department.

Low-perceived work ability, ageing and intention to leave nursing: a comparison among 10 European countries.

AIM: This paper reports a study exploring nurses' perceived work ability and its associations with age and intention to leave nursing in a representative sample of registered nurses in 10 european countries. BACKGROUND: Throughout Europe, there is now a substantial shortage of Registered Nurses and unless steps are taken to reverse this trend, numbers are likely to decline further. A study exploring nurses' perceived work ability will provide baseline evidence, which may lead to improved working conditions and increased nursing retention. METHODS: A cross-sectional study design was employed. Questionnaire data were collected from 25,976 nurses in 10 member states of the European Union between October 2002 and June 2003. The response rate was 52.9% for the total investigation and varied between countries from 32.4% to 76.9%. Perceived work ability was assessed using the Work Ability Index. Intention to leave was measured by asking nurses how often they thought about leaving nursing. Data were examined using analysis of covariance and adjusted logistic regression. RESULTS: In all 10 European countries, scores on the Work Ability Index were significantly lower (P < 0.01) among older nurses (>or=45 years). Work ability varied among countries and differences between younger and older nurses were more pronounced in some countries. In all countries, there was a significant association between low Work Ability Index and intention to leave nursing (odds ratios between 1.98 and 21.46), especially among younger nurses. The association between work ability and intention to leave was most marked for those items on the Work Ability Index which explored subjective rather than objective aspects of work ability. CONCLUSION: Attempts to redress nursing shortages could include institutional policies to sustain work ability through better working conditions, improving quality of the working environment and finding suitable alternative nursing work for those no longer able to cope in their current post. These approaches should include nurses in all age categories.

[Health behavior of healthcare personnel: The European Presst-Next Study]. / Comportements de santé du personnel soignant: Résultats de l'étude européenne Presst-Next.

OBJECTIVES: The objective of the NEXT (Nurses' Early Exit) study was to identify the organizational and health factors in the 10 participating countries associated with job satisfaction of nurses and nurses' aides or with their desire to change occupation or stop working prematurely. METHODS: Questions about health were somewhat more detailed in the French version of the questionnaire and allowed us to determine health behaviors of this representative sample of French caregivers (PRESST: Promotion of Health and Job Satisfaction of European Healthcare Workers [www.next-study.net; www.presst-next.fr]). RESULTS: Of the 6980 (796 men and 6184 women) nurses and nurses' aides studied in late 2002 and early 2003, 32.6% reported that they smoked at least occasionally and 24.3% regularly. Only 24.4% of the staff in our sample exercised at least weekly. Overweight was observed in 27,6% of the sample, mostly women (42% of men and 24.7% of women), and obesity affected 6,4% of men and 7% of women. Overweight was slightly less frequent than among the general adult population of France, 39.8% according to the CREDES SPS survey in 2002, but these healthcare workers were younger. On the whole, burnout was higher among French caregivers than among those from other European nations in the Next study. CONCLUSION: This study demonstrates the need to conduct and assess interventions for the dual purpose of (1) reducing the morbidity and mortality associated with the conditions most sensitive to these risk factors in healthcare personnel and (2) improving their knowledge, motivations and credibility in providing health education to patients.

Nurses' health, age and the wish to leave the profession--findings from the European NEXT-Study.

BACKGROUND AND OBJECTIVES: In many industrialised countries the number of workers with low health is expected to increase in the nursing profession. This will have implications for occupational health work in health care. The European NEXT-Study (www. next-study. net, funded by EU) investigates working conditions of nurses in ten European countries and provides the opportunity to evaluate the role of health with respect to age and the consideration of leaving nursing. METHODS: 26,263 female registered nurses from Belgium, Germany, Finland, France, England, Italy, Netherlands, Poland and Slovakia were eligible for analysis. RESULTS: In most countries, older nurses considered leaving the profession more frequently than younger nurses. 'Health' was--next to 'professional opportunities' and 'work organisational factors'--strongly associated with the consideration of leaving nursing. However, more than half of all nurses with low health wanted to remain in the profession. This group reported rather positive psychosocial working conditions--but also the highest fear for unemployment. CONCLUSIONS: The findings indicate that 'the nurse with low health' is reality in many health care settings. Both positive supporting working conditions but also lack of occupational alternatives and fear of unemployment may contribute to this. Current economic, political and demographic trends implicate that the number of active nurses with low health will increase. Occupational health surveillance will be challenged by this. But NEXT findings implicate that prevention also will have to regard work organisational factors if the aim is to sustain nurses' health and to enable nurses to remain healthy in their profession until retirement age.