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  3. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States
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Research

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1717 (Published 20 March 2012) Cite this as: BMJ 2012;344:e1717
  1. Linda H Aiken, professor and director1,
  2. Walter Sermeus, professor and director2,
  3. Koen Van den Heede, health services research expert17,
  4. Douglas M Sloane, professor 1,
  5. Reinhard Busse, professor and director 3,
  6. Martin McKee, professor 4,
  7. Luk Bruyneel, research fellow 2,
  8. Anne Marie Rafferty, professor 5,
  9. Peter Griffiths, professor 6,
  10. Maria Teresa Moreno-Casbas, director 7,
  11. Carol Tishelman, professor 8,
  12. Anne Scott, professor 9,
  13. Tomasz Brzostek, professor 10,
  14. Juha Kinnunen, professor 11,
  15. Rene Schwendimann, head of education 12,
  16. Maud Heinen, senior researcher 13,
  17. Dimitris Zikos, researcher 14,
  18. Ingeborg Strømseng Sjetne, senior researcher15,
  19. Herbert L Smith, professor and director 16,
  20. Ann Kutney-Lee, assistant professor 1
  1. 1Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA
  2. 2Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
  3. 3Department of Health Care Management, WHO Collaborating Centre for Health Systems, Research and Management, University of Technology Berlin, Berlin, Germany
  4. 4Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
  5. 5Florence Nightingale School of Nursing and Midwifery, King’s College London, London
  6. 6School of Health Sciences, University of Southampton, Southampton, UK
  7. 7National Spanish Research Unit, Instituto de Salud Carlos III, Ministry of Science and Innovation, Madrid, Spain
  8. 8Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden
  9. 9School of Nursing, Dublin City University, Dublin, Ireland
  10. 10Department of Internal Diseases and Community Nursing, Faculty of Health Care, Jagiellonian University Collegium Medicum, Krakow, Poland
  11. 11Department of Health Policy and Management, University of Eastern Finland, Kuopio, Finland
  12. 12Institute of Nursing Science, University of Basel, Basel, Switzerland
  13. 13IQ Healthcare, Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, Netherlands
  14. 14Laboratory of Health Informatics, Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
  15. 15Norwegian Knowledge Centre for the Health Services, Oslo, Norway
  16. 16Population Studies Center, Department of Sociology, University of Pennsylvania, Philadelphia
  17. 17Belgian Healthcare Knowledge Centre, Brussels, Belgium
  1. Correspondence to: L H Aiken laiken{at}nursing.upenn.edu
  • Accepted 25 January 2012

Abstract

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.

Footnotes

  • We thank Tim Cheney and Ryan Lee for their analytical assistance.

  • RN4CAST consortium: Walter Sermeus (Director), Koen Van den Heede, Luk Bruyneel, Emmanuel Lesaffre, Luwis Diya (Belgium, Catholic University Leuven); Linda Aiken (codirector), Herbert Smith, Timothy Cheney, Douglas Sloane (USA, University of Pennsylvania); Anne Marie Rafferty, Jane Ball, Simon Jones, Brian McIntosh (UK, King’s College London); Peter Griffiths (UK, University of Southampton); Juha Kinnunen, Anneli Ensio, Virpi Jylhä (Finland, University of Eastern Finland); Reinhard Busse, Britta Zander, Miriam Blümel (Germany, Technical University Berlin); John Mantas, Dimitrios Zikos (Greece, University of Athens); Anne Scott, Anne Matthews, Anthony Staines (Ireland, Dublin City University); Ingeborg Strømseng Sjetne, Christine Tvedt, Jon Helgeland (Norway, Norwegian Knowledge Centre for the Health Services); Tomasz Brzostek, Maria Kózka, Piotr Brzyski, Lucyna Przewoźniak, Anna Ksykiewicz-Dorota (Poland, Jagiellonian University Collegium Medicum, Medical University of Lublin); Teresa Moreno-Casbas, Carmen Fuentelsaz-Gallego, Esther Gonzalez-María, Monica Contreras-Moreira (Spain, Institute of Health Carlos III); Carol Tishelman, Rikard Lindqvist, Sara Runesdotter, Lisa Smeds (Sweden, Karolinska Institute); Sabina De Geest, Maria Schubert, René Schwendimann (Switzerland, Basel University); Maud Heinen, Lisette Schoonhoven, Theo van Achterberg (Netherlands, Radboud University Nijmegen Medical Centre); advisers were Martin McKee (UK, London School of Hygiene and Tropical Medicine) and Mireille Kingma (Switzerland, International Council of Nurses). See www.rn4cast.eu for additional information.

  • Contributors: LHA, WS, KVH, DMS, RB, MMcK, LB, AMR, PG, and AKL reviewed the literature, interpreted international data, and participated in writing this manuscript. WS and LHA codirected the parent study. All authors contributed to study design and implementation, data collection, conducted country data analyses, and interpreted national data for this paper. All authors contributed to and approved the final manuscript. LHA is the guarantor.

  • Funding: This research received funding from the European Union’s Seventh Framework Programme (FP7/2007-2013, grant agreement no 223468) and the National Institute of Nursing Research, National Institutes of Health (R01NR004513). Funding sponsors had no role in study design, implementation, manuscript development, or decision to publish.

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: funding from the European Union’s Seventh Framework Programme and the National Institute of Nursing Research, National Institutes of Health; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The European study protocol was reviewed and approved by the lead university, Catholic University of Leuven, Belgium. Additionally, each grantee organisation in each of the 12 participating countries received ethical approval at the institutional level to conduct patient and nurse surveys. We also obtained country level approvals to acquire patient outcomes data. US data were collected under a protocol reviewed and approved by the University of Pennsylvania Institutional Review Board.

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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