Nurses' self-regulated learning in clinical wards: Important insights for nurse educators from a multi-method research study.

Central in nurse education curricula stands the preparation of future nurses to work in quickly evolving, dynamic, clinical wards. Learning in the flow of work plays a pivotal role in initial nurse education, but also during continuous professional development. To drive their ongoing development, nurses need competency in self-regulation of learning (SRL). Despite the importance of SRL in the clinical workplace for all (future) healthcare professionals, research on self-regulated workplace learning (SRwpL) of nurses and future nurses in clinical wards is underdeveloped. This study aims to enhance the conceptual understanding of SRwpL strategies and practices in clinical nursing wards and to offer insights for designing effective educational interventions supporting the facilitation and development of (future) nurses' SRwpL in the clinical ward. A multi-actor, multi-method perspective was adopted to qualitatively investigate SRwpL strategies nurses engaged in. Nurses were observed and interviewed, but also professionals responsible for ongoing development in clinical wards (the ward's head nurses and learning counselors) were interviewed. The data collection took place before the COVID pandemic. Results reveal self-regulatory strategies conditional for SRwpL in addition to strategies initiating, progressing, and evaluating the learning process. Head nurses and learning counselors report a lack of these conditional strategies and little variation, and sporadic engagement in all other self-regulatory strategies. To enhance (future) nurses' SRwpL, we suggest that clinical supervisors from educational institutions could exert a lasting influence by not only educating student nurses, but also fostering further professional development of counselors and head nurses to scaffold the SRwpL processes of future nurses in clinical wards.

Measuring the work environment among healthcare professionals: Validation of the Dutch version of the Culture of Care Barometer.

OBJECTIVES: A positive work environment (WE) is paramount for healthcare employees to provide good quality care. To stimulate a positive work environment, employees' perceptions of the work environment need to be assessed. This study aimed to assess the reliability and validity of the Dutch version of the Culture of Care Barometer (CoCB-NL) survey in hospitals. METHODS: This longitudinal validation study explored content validity, structural validity, internal consistency, hypothesis testing for construct validity, and responsiveness. The study was conducted at seven departments in two Dutch university hospitals. The departments were included based on their managers' motivation to better understand their employees' perception of their WE. All employees of participating departments were invited to complete the survey (n = 1,730). RESULTS: The response rate was 63.2%. The content of the CoCB-NL was considered relevant and accessible by the respondents. Two factor models were found. First, confirmative factor analysis of the original four-factor structure showed an acceptable fit (X2 2006.49; df 399; p = <0.001; comparative fit index [CFI] 0.82; Tucker-Lewis index [TLI] 0.80; root mean square error of approximation [RMSEA] 0.09). Second, explanatory factor analysis revealed a five-factor model including 'organizational support', 'leadership', 'collegiality and teamwork', 'relationship with manager', and 'employee influence and development'. This model was confirmed and showed a better fit (X2 1552.93; df 395; p = < 0.00; CFI 0.87; TLI 0.86; RMSEA 0.07). Twelve out of eighteen hypotheses were confirmed. Responsiveness was assumed between the measurements. CONCLUSIONS: The CoCB-NL is a valid and reliable instrument for identifying areas needing improvement in the WE. Furthermore, the CoCB-NL appears to be responsive and therefore useful for longitudinal evaluations of healthcare employees' work environments.

Uniformity along the way: A scoping review on characteristics of nurse education programs worldwide.

BACKGROUND: The changing demands on healthcare require continuous development and education in the nursing profession. Homogeneity in nursing qualifications reduces educational inconsistencies between and within countries. However, despite various initiatives, modifying nurse education remains challenging because different countries have their own legislations, structures, motivations, and policies. OBJECTIVES: To summarize the characteristics of nurse education programs around the globe and analyze the similarities and differences between them. DESIGN AND METHODS: A scoping review was performed to identify different characteristics of nurse education programs in Organization for Economic Co-operation and Development (OECD) countries. Records published between January 2016 and July 2021 were searched in the PubMed, Cinahl, and ERIC databases. The reference lists of all included articles were also searched manually for relevant studies. Articles were eligible if they described nurse education in one or more of the selected countries with a focus on nursing degrees (both undergraduate and postgraduate programs), nursing titles, program duration, study load hours, or practice hours. Data were independently extracted using a predefined extraction sheet. We asked the respective nursing associations for confirmation and to provide any additional information. RESULTS: After searching 9769 records, 117 were included in the synthesis. The included records described characteristics of undergraduate nursing educational programs (n = 50), postgraduate programs (n = 30), or both (n = 37). In total, 86 undergraduate and 82 postgraduate programs were described, with a great variety in degrees, nursing titles, study load hours, and practice hours. CONCLUSIONS: This study demonstrates that there is still considerable variation in nurse education programs between countries. These diverse educational pathways lead to different nursing titles and internationally standardized definitions of nursing roles have not been established. This makes it difficult to understand the healthcare role of nurses. Hence, efforts are needed to increase the quality and uniformity of nurse education around the world.

The Nurse Perceived Adequacy of Staffing Scale for general hospital wards: A development and psychometric validation study.

Background: Adequate staffing is crucial for high quality patient care and nurses' wellbeing. Nurses' professional assessment on adequacy of staffing is the gold standard in measuring staffing adequacy. However, available measurement instruments lack reliability and validity. Objectives: To develop and psychometrically test an instrument to measure nurses' perceived adequacy of staffing (PAS) of general hospital wards. Design: A multicenter cross-sectional psychometric instrument development and validation study using item response theory. Settings: Ten general nursing wards in three teaching hospitals in the Netherlands. Participants: A sample of 881 participants, including third and fourth year nursing students and nurse/care assistants. Methods: The 13-item self-reported questionnaire was developed based on a previous Delphi study and two focus groups. We interviewed five nurses to evaluate the content validity of the instrument. The field test for psychometric evaluation was conducted on ten general wards of three teaching hospitals in the Netherlands. Structural validity of the item bank was examined by fitting a graded response model (GRM) and inspecting GRM fit. Measurement invariance was assessed by evaluating differential item functioning (DIF) of education level and work experience. We examined convergent validity by testing the hypothesis that there was at least a moderate correlation between the PAS instrument and a single item measuring adequacy of staffing. Internal consistency and reliability across the scale were also examined. Results: A total of 881 measurements were included in the analysis. The data fitted the GRM adequately and item fit statistics were good. DIF was detected for work experience for the protocols item, but the impact on total scores was negligible. The hypothesis was confirmed and the item bank reliably measured two standard deviations around the mean. Conclusions: The Nurse Perceived Adequacy of Staffing Scale (NPASS) for nurses of general hospital wards in the Netherlands has sufficient reliability and validity and is ready for use in nurse staffing research and practice.

Nurse Leadership and Work Environment Association with Outcome Expectancy and Self-Efficacy in Evidence-Based Practice among Hospital Nurses in The Netherlands: A Cross-Sectional Study.

The active participation of nurses in evidence-based practice (EBP) is challenging and topical, as shown by the worldwide calls for appropriate, accessible, affordable care and the de-implementation of unnecessary care. Nurses' perceived support from their managers and work environments may affect their self-efficacy and outcome expectancy in EBP, as well as hinder them in EBP. Associations between these issues have not yet been explored. This study examines the association of self-efficacy and outcome expectancy levels in EBP, as well as the perceived support for EBP from nurse leaders and in the working environment, among Dutch hospital nurses. METHODS: Questionnaires measuring nurses' self-efficacy, outcome expectancy, and perceived support for EBP from nurse leaders and their work environment were completed by 306 nurses in eight hospitals between March 2021 and June 2021. We used multilevel regression analyses to determine the associations and covariates. RESULTS: This study shows that EBP-supportive leaders and work environments positively contribute to nurses' self-efficacy and outcome expectancy in EBP, along with the covariates undertaking EBP activities and educational level. CONCLUSIONS: To improve nurses' active participation in EBP, nurses need to increase their self-efficacy and outcome expectancy in EBP. Supportive leaders and a supportive work environment do have an impact. Hence, these factors need attention when implementing EBP among nurses.

Differentiated nursing practice as a catalyst for transformations in nursing: A multiphase qualitative interview study.

AIM: To identify and follow-up on the transition towards differentiated nursing practice among bachelor trained and vocationally trained nurses in Dutch hospitals. DESIGN: A multiphase general qualitative interview study. METHODS: Fifty semi-structured interviews with project managers in charge of introducing differentiated nursing practice to their hospital were conducted. Purposive sampling was used, and data were collected in 2017, 2019 and 2020. A meta-analysis was conducted after independent primary thematic analysis of each data collection. RESULTS: The introduction of differentiated nursing practice to Dutch hospitals was perceived as uncertain and ambiguous. Three themes were identified during the transition towards differentiated nursing practice: (1) call to action; (2) sitting and waiting; and (3) new beginnings and open ends. The change to differentiated nursing practice is not straightforward and these findings highlight the emerging awareness among project managers of the nature and complexity of the transition. During the study period, professionalization of the nursing profession was recognized as fundamental in hospital organizations. CONCLUSION: Nursing cannot be separated from differentiated nursing practice. Visible leadership is important at all organizational levels and nurses' opinions must be considered as nurses are essential to such changes in healthcare. IMPACT: Differentiated nursing practice based on nursing education allows nurses to make the best use of their experience, skills and competencies, and could promote the provision of effective and high-quality patient care. However, in many cases, a nurse's practice role is based on their nursing licensure instead of their educational background. The change to differentiated nursing practice in hospitals is not straightforward and the nature and complexity of the transition needs to be acknowledged. Nurses have an important role in healthcare transformation and need to be active in developing and formulating rather than just implementing the changes.

Defining a positive work environment for hospital healthcare professionals: A Delphi study.

INTRODUCTION: The work environment of healthcare professionals is important for good patient care and is receiving increasing attention in scientific research. A clear and unambiguous understanding of a positive work environment, as perceived by healthcare professionals, is crucial for gaining systematic objective insights into the work environment. The aim of this study was to gain consensus on the concept of a positive work environment in the hospital. METHODS: This was a three-round Delphi study to establish consensus on what defines a positive work environment. A literature review and 17 semi-structured interviews with experts (transcribed and analyzed by open and thematic coding) were used to generate items for the Delphi study. RESULTS: The literature review revealed 228 aspects that were clustered into 48 work environment elements, 38 of which were mentioned in the interviews also. After three Delphi rounds, 36 elements were regarded as belonging to a positive work environment in the hospital. DISCUSSION: The work environment is a broad concept with several perspectives. Although all 36 elements are considered important for a positive work environment, they have different perspectives. Mapping the included elements revealed that no one work environment measurement tool includes all the elements. CONCLUSION: We identified 36 elements that are important for a positive work environment. This knowledge can be used to select the right measurement tool or to develop interventions for improving the work environment. However, the different perspectives of the work environment should be considered.

Patients want to be seen: The top 3 information needs of patients with inguinal hernia.

BACKGROUND: Good patient information has shown to improve surgical outcomes. In this study we explore what kind of pre-surgical information patients need and if the provision of a 360˚ video of a surgical procedure can be of added value to the information provided by the hospital. METHODS: An explorative qualitative study using semi-structured interviews on information needs was conducted among 17 inguinal hernia patients to gain more insight in the patients' present surgical information needs. Patients either were planned to receive or already had received a surgical procedure. Questions were asked about the current information provision and, after being shown a 360˚ video of the surgery, whether this would be of added value. RESULTS: Of the total group of 17 patients (mean age 56, interquartile range 45-64) 16 were male and one was female. Most had no previous experience with virtual reality (14/17), already had undergone a surgical procedure (11/17). Patient information needs were all about "seeing" which can be viewed from three different perspectives [1] being seen as a unique person in the treatment process, [2] being seen as a partner, and [3] seeing is understanding. Patients wanted the contact with the doctor to be more personal, with the possibility to see the anesthetist in person, the surgeon to see their wound in the recovery phase, and to receive personal answers to questions about their specific situation. Patients found the 360-video not fearsome, and believed that visual content could be beneficial as it appeals more to their imagination than written or oral information and increases their understanding. It also provided them with a better understanding of their treatment options, their pre-, peri-, and post-surgical procedures and identification of the cause of post-operative side effects. CONCLUSION: To address patients' information needs, complementary tools or services are needed that increase personal contact as well as tailor it to individual patient's needs. Even though video-apps are a partial alternative, hospitals should still offer patients the possibility of having face-to-face meetings with physicians as this is highly valued by patients and leads to increased trust in physicians' performance.

Psychometric evaluation of instruments measuring the work environment of healthcare professionals in hospitals: a systematic literature review.

PURPOSE: Research shows that the professional healthcare working environment influences the quality of care, safety climate, productivity, and motivation, happiness, and health of staff. The purpose of this systematic literature review was to assess instruments that provide valid, reliable and succinct measures of health care professionals' work environment (WE) in hospitals. DATA SOURCES: Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, CINAHL EBSCOhost and Google Scholar were systematically searched from inception through December 2018. STUDY SELECTION: Pre-defined eligibility criteria (written in English, original work-environment instrument for healthcare professionals and not a translation, describing psychometric properties as construct validity and reliability) were used to detect studies describing instruments developed to measure the working environment. DATA EXTRACTION: After screening 6397 titles and abstracts, we included 37 papers. Two reviewers independently assessed the 37 instruments on content and psychometric quality following the COSMIN guideline. RESULTS OF DATA SYNTHESIS: Our paper analysis revealed a diversity of items measured. The items were mapped into 48 elements on aspects of the healthcare professional's WE. Quality assessment also revealed a wide range of methodological flaws in all studies. CONCLUSIONS: We found a large variety of instruments that measure the professional healthcare environment. Analysis uncovered content diversity and diverse methodological flaws in available instruments. Two succinct, interprofessional instruments scored best on psychometrical quality and are promising for the measurement of the working environment in hospitals. However, further psychometric validation and an evaluation of their content is recommended.

Nurse practitioners' perceptions of their ability to enact leadership in hospital care.

AIMS AND OBJECTIVE: To gain insight into nurse practitioners' (NP) leadership roles in Dutch hospital care, by exploring the perceptions regarding their current leadership role and the differences with their previous role as a registered specialised nurse. BACKGROUND: To meet today's challenges of the increasing healthcare demands, the employment of NPs is proliferating. NPs have the ideal position to play a pivotal role within healthcare reforms, yet full expansion of their scope of practice and expertise is having limited success. Long-term sustainability of NPs depends on the ability to perform and develop a leading role. DESIGN AND METHODS: This qualitative descriptive study was conducted in fifteen Dutch hospitals. Data were collected from April-July 2018, and purposive sampling was used for eighteen semi-structured interviews. This study is conducted and reported according to the COREQ checklist. RESULTS: Three main themes concerning NPs' current leadership role emerged, and they were all linked to a successful positioning of NPs. All themes seemed to be of influence on NPs' scope of daily practice. Direct patient care was emphasised, and leadership on other levels appeared to be underused. Most NPs desired to reshape their profession. However, unprofitable use of their leadership skills especially on professional and organisational level and lack of supportive factors seemed to hinder them. CONCLUSIONS: An adequate use of leadership is crucial for role development and positioning of NPs. Further development of the NP profession can help to better differentiate between the tasks of registered specialised nurses and NPs. RELEVANCE TO CLINICAL PRACTICE: Leadership in nursing contributes to the improvement of the quality and efficiency of health care. Further positioning of the NP profession depends on a profitable use of leadership competencies. Besides, NPs should collaborate with healthcare organisations, educational institutions and professional associations to value the NP profession in the current healthcare system.

An integrative review of leadership competencies and attributes in advanced nursing practice.

AIM: To establish what leadership competencies are expected of master level-educated nurses like the Advanced Practice Nurses and the Clinical Nurse Leaders as described in the international literature. BACKGROUND: Developments in health care ask for well-trained nurse leaders. Advanced Practice Nurses and Clinical Nurse Leaders are ideally positioned to lead healthcare reform in nursing. Nurses should be adequately equipped for this role based on internationally defined leadership competencies. Therefore, identifying leadership competencies and related attributes internationally is needed. DESIGN: Integrative review. METHODS: Embase, Medline and CINAHL databases were searched (January 2005-December 2018). Also, websites of international professional nursing organizations were searched for frameworks on leadership competencies. Study and framework selection, identification of competencies, quality appraisal of included studies and analysis of data were independently conducted by two researchers. RESULTS: Fifteen studies and seven competency frameworks were included. Synthesis of 150 identified competencies led to a set of 30 core competencies in the clinical, professional, health systems. and health policy leadership domains. Most competencies fitted in one single domain the health policy domain contained the least competencies. CONCLUSIONS: This synthesis of 30 core competencies within four leadership domains can be used for further development of evidence-based curricula on leadership. Next steps include further refining of competencies, addressing gaps, and the linking of knowledge, skills, and attributes. IMPACT: These findings contribute to leadership development for Advanced Practice Nurses and Clinical Nurse Leaders while aiming at improved health service delivery and guiding of health policies and reforms.

The difference in endoscopic yield in patients with either iron-deficiency anemia or anemia with normal ferritin.

OBJECTIVE: Current guidelines recommend a gastroduodenoscopy (GDS) and colonoscopy in patients with iron-deficiency anemia (IDA). However, in daily practice, patients with nonferriprive anemia are also referred for endoscopy. The aim of this study is to compare the diagnostic yield of colonoscopy and GDS in patients with IDA and non-IDA. PATIENTS AND METHODS: A retrospective single-center cohort study was carried out from January 2013 till February 2016 that included 917 patients with anemia. We compared the endoscopic yield in patients with IDA versus patients with anemia otherwise. Multivariate regression analyses were carried out to identify predictive factors for the diagnostic yield of GDS and colonoscopy. RESULTS: The yield of both GDS (25%) and colonoscopy (30%) was comparable in IDA and non-IDA patients. However, in patients without known gastrointestinal medical history and without concomitant indications for endoscopy (N=373), the diagnostic yield of GDS was three times higher in IDA patients compared with non-IDA patients (P<0.01). The diagnostic yield for colonoscopy was not significantly different between the two groups. Age and sex were recurrent predictive variables in the outcome of both GDS and colonoscopies. CONCLUSION: We recommend IDA as well as non-IDA as indications for GDS and colonoscopy. Only in patients without gastrointestinal history or localizing complaints a significant difference in the diagnostic yield is found between IDA and non-IDA patients. In this group, upper endoscopy can be omitted in non-IDA patients as they were three times less likely to have a bleeding source found on GDS compared with IDA patients.

Combining clinical practice and academic work in nursing: A qualitative study about perceived importance, facilitators and barriers regarding clinical academic careers for nurses in university hospitals.

AIMS AND OBJECTIVES: To obtain in-depth insight into the perceptions of nurse academics and other stakeholders regarding the importance, facilitators and barriers for nurses combining clinical and academic work in university hospitals. BACKGROUND: Combining clinical practice and academic work facilitates the use of research findings for high-quality patient care. However, nurse academics move away from the bedside because clinical academic careers for nurses have not yet been established in the Netherlands. METHODS: This qualitative study was conducted in two Dutch university hospitals and their affiliated medical faculties and universities of applied sciences. Data were collected between May 2015 and August 2016. We used purposive sampling for 24 interviews. We asked 14 participants in two focus groups for their perceptions of importance, facilitators and barriers in nurses' combined clinical and academic work in education and research. We audiotaped, transcribed and thematically analysed the interviews and focus groups. RESULTS: Three themes related to perceived importance, facilitators and barriers: culture, leadership and infrastructure. These themes represent deficiencies in facilitating clinical academic careers for nurses. The current nursing culture emphasises direct patient care, which is perceived as an academic misfit. Leadership is lacking at all levels, resulting in the underuse of nurse academics and the absence of supporting structures for nurses who combine clinical and academic work. CONCLUSIONS: The present nursing culture appears to be the root cause of the dearth of academic positions and established clinical academic posts. RELEVANCE TO CLINICAL PRACTICE: A culture change would require a show of leadership that would promote and enable combined research, teaching and clinical practice and that would introduce clinical academic career pathways for nurses. Meanwhile, nurse academics should collaborate with established medical academics for whom combined roles are mainstream, and they should take advantage of their established infrastructure for success.

The effect of structural empowerment of nurses on quality outcomes in hospitals: a scoping review.

AIM: To assess and synthesise studies reporting direct associations between the structural empowerment of frontline nurses and quality outcomes, and to identify gaps in the current literature. BACKGROUND: The empowerment of nurses seems essential for delivering high-quality patient care. Understanding the relationship between empowerment and quality outcomes would enable nurse managers to make informed choices on improving the quality of care. METHODS: A scoping review examining the relationship between the structural empowerment of nurses and the quality, effectiveness, safety, efficiency and patient-centredness of care in hospitals. Searching in MEDLINE, CINAHL, Business Source Premier and Embase identified 672 potentially relevant articles. Independent selection, quality assessment, data extraction and analysis were completed. RESULTS: Twelve cross-sectional studies originating from North America were included. These studies showed a variety of quality outcomes and statistics used. All studies reported positive associations between the structural empowerment of nurses, nurse assessed quality of care and patient safety climate, and work and unit effectiveness. CONCLUSIONS: Nurses having access to empowering structures positively affects the quality outcomes, i.e. quality, effectiveness, safety, efficiency and patient-centredness of patient care in hospitals. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers and leaders should ensure empowering work conditions for nurses in order to increase hospitals' quality of patient care.

Pre-implementation studies of a workforce planning tool for nurse staffing and human resource management in university hospitals.

AIM: To investigate the reliability, validity and feasibility of the RAFAELA workforce planning system (including the Oulu patient classification system - OPCq), before deciding on implementation in Dutch hospitals. BACKGROUND: The complexity of care, budgetary restraints and demand for high-quality patient care have ignited the need for transparent hospital workforce planning. METHODS: Nurses from 12 wards of two university hospitals were trained to test the reliability of the OPCq by investigating the absolute agreement of nursing care intensity (NCI) measurements among nurses. Validity was tested by assessing whether optimal NCI/nurse ratio, as calculated by a regression analysis in RAFAELA, was realistic. System feasibility was investigated through a questionnaire among all nurses involved. RESULTS: Almost 67 000 NCI measurements were performed between December 2013 and June 2014. Agreement using the OPCq varied between 38% and 91%. For only 1 in 12 wards was the optimal NCI area calculated judged as valid. Although the majority of respondents was positive about the applicability and user-friendliness, RAFAELA was not accepted as useful workforce planning system. CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT: Nurses' performance using the RAFAELA system did not warrant its implementation. Hospital managers should first focus on enlarging the readiness of nurses regarding the implementation of a workforce planning system.

Factors determining the patients' care intensity for surgeons and surgical nurses: a conjoint analysis.

BACKGROUND: Surgeons and nurses sometimes perceive a high workload on the surgical wards, which may influence admission decisions and staffing policy. This study aimed to explore the relative contribution of various patient and care characteristics to the perceived patients' care intensity and whether differences exist in the perception of surgeons and nurses. METHODS: We invited surgeons and surgical nurses in the Netherlands for a conjoint analysis study through internet and e-mail invitations. They rated 20 virtual clinical scenarios regarding patient care intensity on a 10-point Likert scale. The scenarios described patients with 5 different surgical conditions: cholelithiasis, a colon tumor, a pancreas tumor, critical leg ischemia, and an unstable vertebral fracture. Each scenario presented a mix of 13 different attributes, referring to the patients' condition, physical symptoms, and admission and discharge circumstances. RESULTS: A total of 82 surgeons and 146 surgical nurses completed the questionnaire, resulting in 4560 rated scenarios, 912 per condition. For surgeons, 6 out of the 13 attributes contributed significantly to care intensity: age, polypharmacy, medical diagnosis, complication level, ICU-stay and ASA-classification, but not multidisciplinary care. For nurses, the same six attributes contributed significantly, but also BMI, nutrition status, admission type, patient dependency, anxiety or delirium during hospitalization, and discharge type. Both professionals ranked 'complication level' as having the highest impact. DISCUSSION: The differences between surgeons and nurses on attributes contributing to care intensity may be explained by differences in professional roles and daily work activities. Surgeons have a medical background, including technical aspects of their work and primary focus on patient curation. However, nurses are focused on direct patient care, i.e., checking vital functions, stimulating self-care and providing woundcare. CONCLUSIONS: Surgeons and nurses differ in their perception of patients' care intensity. Appreciation of each other's differing interpretations might improve collaboration between doctors and nurses and may help managers to match hospital resources and personnel.

Nurse staffing issues are just the tip of the iceberg: a qualitative study about nurses' perceptions of nurse staffing.

OBJECTIVE: To obtain in-depth insight into the perceptions of nurses in the Netherlands regarding current nurse staffing levels and use of nurse-to-patient-ratios (NPR) and patient classification systems (PCS). BACKGROUND: In response to rising health care demands due to ageing of the patient population and increasing complexity of healthcare, hospital boards have been implementing NPRs and PCSs. However, many nurses at the unit level believe that staffing levels have become critically low, endangering the quality and safety of their patient care. METHODS: This descriptive phenomenological qualitative study was conducted in a 1000-bed Dutch university hospital among 24 wards of four specialties (surgery, internal medicine, neurology, gynaecology & obstetrics and paediatric care). Data were collected from September until December 2012. To collect data four focus groups (n=44 nurses) were organized. Additionally, a total of 27 interviews (20 head nurses, 4 nurse directors and 3 quality advisors) were conducted using purposive sampling. The focus groups and interviews were audiotaped, transcribed and subjected to thematic analysis. RESULTS: Nurse staffing issues appear to be merely the 'tip of the iceberg'. Below the surface three underlying main themes became clear - nursing behaviour, authority, and autonomy - which are linked by one overall theme: nurses' position. In general, nurses' behaviour, way of thinking, decision-making and communication of thoughts or information differs from other healthcare disciplines, e.g. physicians and quality advisors. This results in a perceived and actual lack of authority and autonomy. This in turn hinders them to plead for adequate nurse staffing in order to achieve the common goal of safe and high-quality patient care. Nurses desired a valid nursing care intensity system as an interdisciplinary and objective communication tool that makes nursing care visible and creates possibilities for better positioning of nurses in hospitals and further professionalization in terms of enhanced authority and autonomy. CONCLUSIONS: The perceived subservient position of nurses in the hospital appears to be the root cause of nurse staffing problems. It is yet unknown whether an objective PCS to measure nursing care intensity would help them communicate effectively and credibly, thereby improving their own position.

Quantifying the demand for hospital care services: a time and motion study.

BACKGROUND: The actual amount of care hospitalised patients need is unclear. A model to quantify the demand for hospital care services among various clinical specialties would avail healthcare professionals and managers to anticipate the demand and costs for clinical care. METHODS: Three medical specialties in a Dutch university hospital participated in this prospective time and motion study. To include a representative sample of patients admitted to clinical wards, the most common admission diagnoses were selected from the most recent update of the national medical registry (LMR) of ICD-10 admission diagnoses. The investigators recorded the time spent by physicians and nurses on patient care. Also the costs involved in medical and nursing care, (surgical) interventions, and diagnostic procedures as an estimate of the demand for hospital care services per hospitalised patient were calculated and cumulated. Linear regression analysis was applied to determine significant factors including patient and healthcare outcome characteristics. RESULTS: Fifty patients on the Surgery (19), Pediatrics (17), and Obstetrics & Gynecology (14) wards were monitored during their hospitalization. Characteristics significantly associated with the demand for healthcare were: polypharmacy during hospitalization, complication severity level, and whether a surgical intervention was performed. CONCLUSIONS: A set of predictors of the demand for hospital care services was found applicable to different clinical specialties. These factors can all be identified during hospitalization and be used as a managerial tool to monitor the patients' demand for hospital care services and to detect trends in time.

Factors and models associated with the amount of hospital care services as demanded by hospitalized patients: a systematic review.

BACKGROUND: Hospitals are constantly being challenged to provide high-quality care despite ageing populations, diminishing resources, and budgetary restraints. While the costs of care depend on the patients' needs, it is not clear which patient characteristics are associated with the demand for care and inherent costs. The aim of this study was to ascertain which patient-related characteristics or models can predict the need for medical and nursing care in general hospital settings. METHODS: We systematically searched MEDLINE, Embase, Business Source Premier and CINAHL. Pre-defined eligibility criteria were used to detect studies that explored patient characteristics and health status parameters associated to the use of hospital care services for hospitalized patients. Two reviewers independently assessed study relevance, quality with the STROBE instrument, and performed data analysis. RESULTS: From 2,168 potentially relevant articles, 17 met our eligibility criteria. These showed a large variety of factors associated with the use of hospital care services; models were found in only three studies. Age, gender, medical and nursing diagnoses, severity of illness, patient acuity, comorbidity, and complications were the characteristics found the most. Patient acuity and medical and nursing diagnoses were the most influencing characteristics. Models including medical or nursing diagnoses and patient acuity explain the variance in the use of hospital care services for at least 56.2%, and up to 78.7% when organizational factors were added. CONCLUSIONS: A larger variety of factors were found to be associated with the use of hospital care services. Models that explain the extent to which hospital care services are used should contain patient characteristics, including patient acuity, medical or nursing diagnoses, and organizational and staffing characteristics, e.g., hospital size, organization of care, and the size and skill mix of staff. This would enable healthcare managers at different levels to evaluate hospital care services and organize or reorganize patient care.