Validation of the Nurse Managers' Work Content Questionnaire and Factors-A Structural Equation Modeling Study.

BACKGROUND: The responsibilities of nurse managers are diverse and occasionally inadequately organized. Moreover, the role of nurse manager often lacks a clear job description. Few methodologies for evaluating the content of nurse managers' work exist. PURPOSE: This study was designed to validate the Nurse Managers' Work Content Questionnaire (NMWCQ) instrument and to analyze the relationships between NMWCQ factors and background variables using structural equation modeling. METHODS: A multicenter descriptive and cross-sectional study design was used. The NMWCQ, which includes 87 items across 13 components, was developed based on a comprehensive literature review and pilot study. The questionnaire was sent to all of the nurse managers ( N = 756) employed at eight Finnish hospitals in 2019. Exploratory and confirmatory factor analyses were used to psychometrically test and validate the NMWCQ, whereas Cronbach's alpha values were calculated to explore the internal consistency of the instrument. Structural equation modeling was applied to detect the relationships between the constructed factor structure and the background variables. RESULTS: Two hundred seven nurse managers participated in this study. The final solution for the NMWCQ included 75 items across 12 factors. The NMWCQ factors were as follows: responsibility for new employees, daily management, human resource management, decision making, clinical nursing, development, planning of processes, collaboration, ensuring knowledge, evidence-based management, ensuring care quality, and financial management. The items showed factor loadings that were either positive or negative, with values ranging from .314 to .846. The Cronbach's alpha values for the factors ranged between .605 and .851. All of the covariances and relationships between background variables and factors were found to be significant ( p ≤ .05). The structural equation modeling showed acceptable index results (incremental fit index = .954, comparative fit index = .951, and root mean square error of approximation = .048). CONCLUSIONS: The NMWCQ version assessed in this study shows a more robust structure than the previously published pilot version. Psychometric testing showed the NMWCQ as suitable for describing the diverse work requirements of nurse managers and may offer a framework for concretizing the job description of nurse managers.

Components of the Magnet® model provide structure for the future vision of nurse managers' work: A qualitative perspective of nurse managers.

AIM: To describe nurse managers' views of their work in the future. BACKGROUND: Ongoing reformation of health care organisations includes profound changes to nurse managers' work practices. METHOD: A qualitative approach was applied to elicit views of nurse managers (n = 133) from eight Finnish specialized medical care hospitals through one open-ended question about their future work in November 2019. The acquired data were subjected to inductive thematic content analysis. RESULTS: Four themes were identified in the nurse managers' responses, indicating that they anticipated: 1) a shift from hierarchical leadership to shared governance, 2) an increasing focus on proactive and systematic work, 3) development of evidence-based practices and 4) improvement in the attractiveness and effectiveness of the organisation. CONCLUSIONS: Nurse managers envisage their future work will follow the transformational leadership model. Shared governance and multidisciplinary team leading, with a stronger focus on proactive strategic planning will extend their power to influence decision-making. Administrative supporting systems will free more time from their daily routine work for interactions with staff. IMPLICATIONS FOR NURSING MANAGEMENT: Clarification of the managers' job description along with administrative support systems is anticipated to strengthen leadership, facilitate management, enhance decision-making and increase the attractiveness and effectiveness of both health care organisations and nurse managers' work.

Relationships between nurse managers' work activities, nurses' job satisfaction, patient satisfaction, and medication errors at the unit level: a correlational study.

BACKGROUND: Nurse managers play a critical role in enhancing nursing and patient outcomes. The work of nurse managers, who can be described as middle-managers at health care organizations, is complex and changes on a daily basis. Only a few studies have clarified how nurse managers divide their time across various work activities. This study aimed to describe the relationships between nurse managers' work activities, nurses' job satisfaction, patient satisfaction, and medication errors at the hospital unit level. METHODS: A cross-sectional and correlational study design was used. The data were collected from nurse managers (n = 29), nursing staff (n = 306), and patients (n = 651) from 28 units across three Finnish acute care hospitals between April and November 2017. In addition, data concerning medication errors (n = 468) over one calendar year (2017) were acquired from the hospitals' incident reporting register. Analysis of covariance (ANCOVA) was used to estimate relationships between data from subareas of Nurse Managers' Work Content Questionnaire, Kuopio University Hospital Job Satisfaction Scale, and Revised Humane Caring Scale, along with medication error reports. A significance level of 95% was applied when estimating the covariances between variables. Unstandardized regression coefficients (B) were used to explain the relationships between variables. RESULTS: Multiple relationships between nurse managers' work activities, nurses' job satisfaction, patient satisfaction, and medication errors were identified. Nurse managers' work activities had both positive and negative relationships on the other studied variables. The Requiring factors of work (p < .001) subarea of nurses' job satisfaction, total patient satisfaction (p < .001), and medication errors (p < .001) were identified as the variables most significantly affected by other factors. CONCLUSIONS: The findings suggest that nurse managers should focus on improving nursing practices by managing and organizing nurses' work in a way that makes their employees feel supported, motivated and secure. Furthermore, nurse managers should adopt a leadership style that emphasizes safe and patient-centered care. The results also suggest that the administration of today's health care organizations should actively evaluate nurse managers' share of work activities to ensure that their daily work is in line with the organizational goals.

Nurse managers' work content: development of the questionnaire and results of the pilot study.

AIM: To develop the Nurse Managers' Work Content Questionnaire (NMWCQ) and to describe nurse managers' work content. BACKGROUND: Restructuring within health care has expanded the nurse manager's role to include organisational, patient and staff demands. METHODS: The pilot study employed a cross-sectional study design. Based on a literature review, the NMWCQ with 102 items was developed and pretested for this study. Data were collected in 2017 from three Finnish acute care central hospitals that provide specialised health care. A total of 61 nurse managers participated, which represents a response rate of 59%. Principal component analysis was used to test the construct validity of the instrument. Cronbach's alpha values were used to analyse the internal consistency of the instrument. In addition, descriptive and nonparametric analysis was used. RESULTS: Ultimately, 13 components with 87 items were identified in the questionnaire. The construct validity and internal consistency of the questionnaire were at acceptable levels. Cronbach's alpha rates of the components were 0.554 - 0.890. The most frequently performed daily work of nurse managers was in the component of organising, and the most infrequently performed daily work was in the component of clinical nursing. CONCLUSIONS: The study shows that the Nurse Managers' Work Content Questionnaire (NMWCQ) is suitable for measuring the current content of nurse managers' work. However, the questionnaire is new and needs additional testing such as confirmatory factor analysis with larger amounts of data.

A scoping review of nursing workforce planning and forecasting research.

AIM: This study will critically evaluate forecasting models and their content in workforce planning policies for nursing professionals and to highlight the strengths and the weaknesses of existing approaches. BACKGROUND: Although macro-level nursing workforce issues may not be the first thing that many nurse managers consider in daily operations, the current and impending nursing shortage in many countries makes nursing specific models for workforce forecasting important. METHOD: A scoping review was conducted using a directed and summative content analysis approach to capture supply and demand analytic methods of nurse workforce planning and forecasting. The literature on nurse workforce forecasting studies published in peer-reviewed journals as well as in grey literature was included in the scoping review. RESULTS: Thirty six studies met the inclusion criteria, with the majority coming from the USA. Forecasting methods were biased towards service utilization analyses and were not consistent across studies. CONCLUSION: Current methods for nurse workforce forecasting are inconsistent and have not accounted sufficiently for socioeconomic and political factors that can influence workforce projections. Additional studies examining past trends are needed to improve future modelling. IMPLICATIONS FOR NURSING MANAGEMENT: Accurate nursing workforce forecasting can help nurse managers, administrators and policy makers to understand the supply and demand of the workforce to prepare and maintain an adequate and competent current and future workforce.

Nurses' Time Use in Forensic Psychiatry: Core Interventions Outlined in the Finnish Clinical Practice Guideline on Schizophrenia.

Forensic psychiatric nurses are key in implementing the core interventions outlined in the clinical practice guideline on schizophrenia. This study endeavors to ascertain how these were implemented in routine practice in forensic psychiatry by measuring how nurses use their time. Data were collected from registered nurses and practical mental nurses in all forensic psychiatric facilities in Finland using self-report diary forms for 1 week. In total, nurses used 20% of their weekly working hours on core interventions. The differences between the nurse groups were statistically significant (p ≤ 0.05) regarding the following core interventions: (a) care planning with physicians, (b) pharmacotherapy, and (c) basic clinical care. Nurses' qualifications, types of facilities and units, working experience, gender, and staffing levels explained the time used on core interventions. In summary, forensic psychiatric inpatients received insufficient appropriate nursing services according to the relevant guideline regarding schizophrenia. Furthermore, managerial recommendations need to restructure nurses' time use to increase the proportion of productive working hours spent with patients.

Organization of nursing care in three Nordic countries: relationships between nurses' workload, level of involvement in direct patient care, job satisfaction, and intention to leave.

BACKGROUND: Health care systems in Finland, Norway and Sweden share many similarities, e.g. full-coverage and tax-financed, with predominately public sector hospitals. Despite similarities, there are differences in the working situations for RNs within these Nordic countries. The aim of this study was to analyze associations between RNs' patient workload and level of involvement in direct patient care, their job satisfaction and intention to leave in these countries. METHODS: A workforce survey was conducted through RN4CAST, an EU 7th framework project. The survey included 118 items derived from validated instruments or tested in prior research. Responses from 1133 RNs at 32 Finnish hospitals, 3752 RNs at 35 Norwegian hospitals, and 11 015 RNs at 71 Swedish hospitals comprise the database, which was analyzed using logistic and odds ratio regressions analyses. RESULTS: We found statistically significant differences in RNs' level of involvement in direct patient care (p < 0.001, Sweden compared to Norway and Finland), in patient workload and in number of patients needing ADL assistance and surveillance. A U-formed relationship was found between level of involvement in direct patient care and intention to leave in Sweden, and more satisfaction among RNs in roles with more direct patient care (OR = 1.16, 1.02 ≤ CI95% ≤ 1.32). Nearly half the Finnish sample report intention to leave, with significantly lower levels in Norway and Sweden (p < 0.001). Patient workload is associated with job satisfaction and intention to leave to some degree in all countries, i.e. greater patient workload, less job satisfaction and greater intention to leave. CONCLUSIONS: This study suggests that more attention paid to patient mix, workload and role of RNs in patient care might potentially diminish intention to leave and increase job satisfaction in these Nordic countries.

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.

BACKGROUND: Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures. METHODS: For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics. FINDINGS: An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients. INTERPRETATION: Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths. FUNDING: European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.

Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study.

BACKGROUND: Little is known of the extent to which nursing-care tasks are left undone as an international phenomenon. AIM: The aim of this study is to describe the prevalence and patterns of nursing care left undone across European hospitals and explore its associations with nurse-related organisational factors. METHODS: Data were collected from 33 659 nurses in 488 hospitals across 12 European countries for a large multicountry cross-sectional study. RESULTS: Across European hospitals, the most frequent nursing care activities left undone included 'Comfort/talk with patients' (53%), 'Developing or updating nursing care plans/care pathways' (42%) and 'Educating patients and families' (41%). In hospitals with more favourable work environments (B=-2.19; p<0.0001), lower patient to nurse ratios (B=0.09; p<0.0001), and lower proportions of nurses carrying out non-nursing tasks frequently (B=2.18; p<0.0001), fewer nurses reported leaving nursing care undone. CONCLUSIONS: Nursing care left undone was prevalent across all European countries and was associated with nurse-related organisational factors. We discovered similar patterns of nursing care left undone across a cross-section of European hospitals, suggesting that nurses develop informal task hierarchies to facilitate important patient-care decisions. Further research on the impact of nursing care left undone for patient outcomes and nurse well-being is required.

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.

Costs of intensive psychiatric care for treatment-resistant minors.

BACKGROUND: Mental health problems in childhood and adolescence result in high costs to society. Despite the relevance of these problems, there are still relatively few economic evaluations of this domain, in particular the evaluation of the costs of treatment-resistant minors. AIM OF THE STUDY: The study is aimed to evaluate the costs of mental services use of 52 treatment-resistant minors at the Intensive Psychiatric Care Unit of the Niuvanniemi Hospital, in Kupio, Finland, and the costs of the mental health services used by these patients before their referral to this unit. METHODS: The data were collected from case history files of minors (N 2dd = 2dd 52) who were directed to the intensive psychiatric care unit between 2004 and 2007. The data included information of the use of earlier specialised medical psychiatric care. The study evaluated the cost of daily bed charges for treatment-resistant minors. RESULTS: The mean duration of the intensive psychiatric care unit treatment was twelve months. The average cost was 367,150/patient. Fifty-one per cent of the minors were discharged to less intensive mental health services after the intensive psychiatric care. CONCLUSIONS: The costs of intensive psychiatric treatment are currently high. Benefits may be achieved over time. Further research should monitor and analyse the benefit of such expensive treatment on the outcomes of treatment-resistant patients over time, an investment in the minors' future, that ultimately benefits society.

Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology.

BACKGROUND: 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. METHODS/DESIGN: 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. DISCUSSION: 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.

Interrelationship between core interventions and core competencies of forensic psychiatric nursing in Finland.

The importance of core competencies (CC) and their relationship to core interventions in clinical practice guidelines on schizophrenia (CPGS), and the abilities to master these competencies were studied among registered nurses (RN) and practical mental nurses (PMN) in a forensic psychiatric setting. Data were collected from RNs, PMNs, and managers of all five forensic psychiatric facilities in Finland. The research material was obtained by using a 360-degree feedback method. The response rate was 68% (N = 428). The differences between the nurse groups were statistically significant (p ≤ 0.05) regarding the importance of and ability to master the following CCs: (1) pharmacotherapy, (2) knowledge in forensic psychiatry and violent behavior, (3) the treatment of violent patients, (4) processing patient's and own emotion, and (5) need-adapted treatment of the patient. Overall, RNs exceeded PMNs in mastering the CCs, however the principles of the CPGS were not achieved within the current resources in Finland. In summary, RNs, rather than PMNs, should be recruited for work in forensic psychiatric nursing, although a considerable amount of specific training would still be required to achieve competence. Implications of our research indicate that all nurses working in this area need to receive further education in forensic psychiatry and in forensic psychiatric nursing.

Managers' perspectives on recruitment and human resource development practices in primary health care.

OBJECTIVES: The aim of this study is to describe primary health care managers' attitudes and views on recruitment and human resource development in general and to ascertain whether there are any differences in the views of managers in the southern and northern regions of Finland. STUDY DESIGN: A postal questionnaire was sent to 315 primary health care managers, of whom 55% responded. METHODS: The data were analysed using descriptive statistics and cross-tabulation according to the location of the health centre. RESULTS: There were few differences in managers' attitudes and views on recruitment and human resource development. In the southern region, managers estimated that their organization would be less attractive to employees in the future and they were more positive about recruiting employees abroad. Furthermore, managers in the northern region were more positive regarding human resource development and its various practices. CONCLUSIONS: Although the results are preliminary in nature, it seems that managers in different regions have adopted different strategies in order to cope with the shrinking pool of new recruits. In the southern region, managers were looking abroad to find new employees, while in the northern region, managers put effort into retaining the employees in the organization with different human resource development practices.

Strategic management of health care information systems: nurse managers' perceptions.

The aim of this study is to describe nurse managers' perceptions of the strategic management of information systems in health care. Lack of strategic thinking is a typical feature in health care and this may also concern information systems. The data for this study was collected by eight focus group interviews including altogether 48 nurse managers from primary and specialised health care. Five main categories described the strategic management of information systems in health care; IT as an emphasis of strategy; lack of strategic management of information systems; the importance of management; problems in privacy protection; and costs of IT. Although IT was emphasised in the strategies of many health care organisations, a typical feature was a lack of strategic management of information systems. This was seen both as an underutilisation of IT opportunities in health care organisations and as increased workload from nurse managers' perspective. Furthermore, the nurse managers reported that implementation of IT strengthened their managerial roles but also required stronger management. In conclusion, strategic management of information systems needs to be strengthened in health care and nurse managers should be more involved in this process.

Human resource development in nursing: views of nurse managers and nursing staff.

AIM: This study describes the views of nurse managers and staff members on human resource development (HRD) in health care. Our interest here is whether there are any differences between these two groups. BACKGROUND: The need for HRD in order to cope with an ageing workforce and a diminishing number of younger nurses. METHODS: A postal questionnaire was sent to a random sample of nursing staff (n = 653) and all nurse managers (n = 302) in six Finnish hospital districts in spring 2005. The data were analysed by statistical methods. RESULTS: The nurse managers placed more emphasis on human resource development than did staff members. In general, both the nurse managers and nursing staff held positive views on human resource development, but they reported that HRD practices were quite under-developed. Some differences emerged between the groups. CONCLUSIONS AND IMPLICATIONS FOR NURSING MANAGEMENT: These findings underline the importance of human resource development and its practices in health care. Nurse managers need to implement strategically steered HRD in order to maintain high quality of care in the future.

What degree of work overload is likely to cause increased sickness absenteeism among nurses? Evidence from the RAFAELA patient classification system.

AIM: This paper reports a study examining whether nurses' work overload is associated with increased sick leave and quantifying the loss of working days from work overload. BACKGROUND: The RAFAELA patient classification system indicates nursing care intensity in relation to an optimum and is one of the few validated monitoring instruments of patient-associated workload among nurses. However, it is not clear whether work overload is a risk factor for increased sickness absenteeism, an important occupational problem in health care. METHOD: An observational cohort study was carried out with 877 nurses, 31 wards and five Finnish hospitals. Patient-associated workload scores from the RAFAELA system were based on a 6-month monitoring period in 2004. Records of 12-month self certified (1-3 days) and medically certified (>3 days) periods of sick leave in the same year were obtained from employers' registers. FINDINGS: The mean workload was 9% (sd = 8%) above the optimum. There was a linear trend between increasing workload and increasing sick leave (P < or = 0.006). Among nurses with workload > or =30% above the optimum the rate of self certified periods of sick leave was 1.44 (95% CI 1.13-1.83) times higher than among those with an optimum workload. The corresponding rate ratio for medically certified sick leave was 1.49 (1.10-2.03). These excess rates of sickness absence resulted in 12 extra sick leave days per person-year. CONCLUSION: Measuring nurses' workload may be an important part of strategic human resource management of nurses to reduce sick leave among nurses.

Commitment of project participants to developing health care services based on the internet technology.

BACKGROUND: When developing Information and Communication Technology (ICT), such as services for the decision-making process, skilled health care professionals with their comprehensive knowledge of patients/clients are essential contributors to the project. Careful evaluation is needed to assess the effectiveness of project management as well as to analyze the commitment of the personnel to goal attainment. OBJECTIVE: In the course of the development of integrated maternity care services, the commitment of project participants (n=48) was evaluated. What factors enhanced or impaired their commitment to the project work? METHODS: Questionnaire (n=80, response rate 60%) with quantitative analysis as well as open-ended questions with qualitative content analysis. RESULTS: Positive commitment was related to a confidential and open atmosphere during the project. The utilization of personal skills and experience was appreciated. Differences in the working principles and cultures between the participating organizations complicated fluent collaboration. To encourage commitment, a lot of attention should be paid to internal communication as well as the effective realization of project tasks. CONCLUSION: The strength of the project was the highly innovative and confidential atmosphere. The well-established project goals, the highly inspired project team, and the effective co-operation between the project manager and the core group helped to deepen overall commitment in the project.