Efectividad en la reducción de desigualdades en salud

The studies discussed in the previous section were mostly based on administrative data related to nurse staffing and patient outcome. Other literature suggests that nurse staffing levels affect nurses’ job satisfaction and the level of burnout and intention to leave their current job or nursing.

In a previous study, Aiken et al (2002b) (2.3.3) also examined the association between nurse staffing and burnout and job satisfaction among RNs. Burnout was Emotional Exhaustion that is a part of Maslach’s Burnout Inventory (MBI) and job satisfaction was ranked from; very satisfied, satisfied, dissatisfied, and very dissatisfied. It was found that a high patient to nurse ratio was associated with high emotional exhaustion and job dissatisfaction; that is every additional patient per nurse increases burnout by 23% (OR,1.23; 95%CI, 1.13-1.34; P,0.01) and job dissatisfaction by 15% (OR, 1.15; 95%CI, 1.07-1.25; p<0.001). The result suggested that the lower nursing staffing level had a negative impact on nurses’ well being as well as patient mortality.

A study was conducted in 65 ICUs from 22 Korean hospitals to examine the relationship between nurse staffing and the quality of patient care, job satisfaction, burnout, and RNs’ intention to leave the job (Cho et al., 2009). A cross sectional design was applied including a survey with staff nurses (n=1,365). Hospitals were located in Seoul or nearby and were well-known general hospitals providing secondary or tertiary care. Two different nurse surveys were distributed; one for nurse managers (n=65) and the other for RNs (n=1365). The ICU characteristics and nurse staffing data were collected from the nurse managers’ questionnaire, which asked type of ICU, number of ICU beds, and number of RNs working in each shift and etc. The questionnaire for RNs asked their perception of staff adequacy, quality of nursing care in the unit, and job satisfaction on a four point scale. Burnout was measured with nine items from the Maslach Burnout Inventory measuring Emotional Exhaustion. After adjusting for hospital, ICU and RN characteristics, it was revealed that the number of patients per RN and the perception of staff adequacy were associated with the perceived quality of patient care. RNs with a lower number of patients (2 or fewer patients) to care for were more likely to report a higher perceived quality of care compare to RNs with three or more patients to care (OR, 3.26; 95%CI. 1.14-9.31; P<0.05). RNs who perceived the staffing as adequate were more likely to report a higher quality of care (OR, 2.97; 95%CI, 2.22-3.97, p<0.05). In addition, RNs who perceived the staffing as adequate were less likely to be dissatisfied with their job (OR, 0.30; 95%CI, 0.23-0.40; p<0.05), burnout (OR, 0.50; 95%CI, 0.34-0.40; p<0.05), or leave their job (OR, 0.40; 95%CI, 0.28-0.56, p<0.05). However, no significant association was found between the number of patients per RN and job dissatisfaction, burnout, and intention to leave. The study was conducted in are particular area of Korea and this may not reflect RNs working in other units or other regions in Korea. The result implied that the same nursing staffing level (the number of patients per nurse) among the units does not give the same perception of staff adequacy among staff nurses.

Another study was conducted to examine the net effect of the nurse practice environment on negative job outcomes such as burnout, job satisfaction and intention to leave (Aiken 2008) (2.3.4). Negative job outcomes were measured by MBI, job satisfaction and their intention to leave. It was revealed that a higher portion (50.8%) of RNs reported a high level of burnout (MBI score above 27) in the ‘poor’ hospital category compared to the ‘better’ hospital category (36.3% of RNs reported high level of burnout) as well as greater job dissatisfaction (47.9%of RNs in ‘poor’ category hospital and 33.5% of RNs in ‘better’ hospital categories). After the calculation of odds ratio, it was revealed that RNs in poor/mixed work environments were more likely to be ‘burnt-out’ by 24% (OR: 0.76, 95%CI:0.70-0.82,p<0.01), be dissatisfied with their job by 25% (OR:0.75, 95%CI:0.68- 0.81, p<0.01), and have an intention to leave within 1 year by 13% (OR:0.84, 95%CI:0.79- 0.96, p<0.01) compared to mixed/better work environments. Thus RNs in the better work environment had a lower odds ratio of experiencing burnout, job dissatisfaction and intention to leave by 24% (1-0.872)-42 %( 1-0.742).

An international comparison study was conducted to examine the effect of work environment on hospital outcomes such as nurses’ burnout, job satisfaction, and the quality of nursing care (Aiken, Sloane, Clarke, Poghosyan, Cho, You, Finlayson, Kanai-Pak and Aungsuroch, 2011). A survey was conducted using a common instrument with 98,116 nurses (definition not provided in some countries) in 1,406 hospitals in 9 countries (USA, China, South Korea, Thailand, Japan, New Zealand, UK, Canada, Germany) from 1999 to 2009. The study was originally a collaborative research project including five countries (USA, England, Scotland, Canada and Germany) (Aiken, Clarke, Sloane, Sochalski, Busse, Clarke, Giovannetti, Hunt, Rafferty and Shamian, 2001). They used a common protocol in 1999 and the study was replicated in New Zealand (2004), USA (2006), Japan (2006), Thailand (2007), South Korea (2008), and China (2009). Nurses were sampled from adult acute hospitals in each country. The hospitals were sampled either; randomly from all hospitals in the region (England and Germany), or all hospitals in that region were included (Scotland, USA, Canada, New Zealand), or by a stratified sample of government regional hospital (Thailand, China, South Korea), or by a convenience sample (Japan). Nurses who were approached were all RNs in the study region, or all RNs working at the target hospitals. The work environment was measured by 28 items of PES-NWI (Lake, 2002). The median score was used rather than mean score to adjust the variation of work environment and interpretation of the items. There were four outcome variables; nurse burnout measured by Maslach Burnout Inventory, job satisfaction distinguished by four categories ;very satisfied’ to ‘very dissatisfied’, quality of care, patients’ readiness of

discharge. The results showed one third of the UK hospitals were categorized as ‘better’ as they scored 4-5 subscales above country’s median and 28.3% of them were categorized as ‘poor’ as they scored 0-1 subscales above country’s median. In contrast, 36.8% of Japanese hospitals were categorised as ‘better’ and 26.3% of them were ‘poor’. However, it is difficult to simply compare as the UK data were collected in 1999 and Japanese data were collected in 2006.

Key Message and Summary

There is consistent evidence that nursing staffing level is related to the perceived quality of care as well as patient outcome (Aiken et al., 2002b; Needleman et al., 2002; Rafferty et al., 2007). Additionally, an association between nursing staffing levels and nurses’ job satisfaction and the level of burnout was found. As a result of these studies, nursing staff and their working environment received an attention within healthcare settings and nurses became a key factor to deliver high quality of healthcare within the public sector (Scottish Executive, 2005a).