Work and health of nurses in Europe

Transcription

1 Work and health of nurses in Europe results from the NEXT-Study H.M. Hasselhorn P. Tackenberg A. Buescher M. Simon A. Kuemmerling B.H. Mueller University of Wuppertal FB - D Dept. Safety Engeneering Occupational Safety/Ergonomics Gaußstraße 2, D Wuppertal, Germany next@uni-wuppertal.de University of Witten/Herdecke ggmbh Faculty of Medicine, Institute of Nursing Science Stockumer Straße 12, D Witten, Germany

2 Work and health of nurses in Europe results from the NEXT-Study H.M. Hasselhorn, P. Tackenberg, A. Buescher, M. Simon, A. Kuemmerling, B.H. Mueller Aim of this document The European NEXT-Study is assessing premature departure from the nursing profession in ten European countries. A large amount of data has been collected, with more than 56, nurses participating in NEXT, opening the unique possibility to compare nurses work on an international level with respect to socioeconomic background, working conditions and relevant outcomes such as health. The aim of this paper is to provide an overview of key indicators of nursing work in Europe and to deliver a basis for a debate on nursing among stakeholders in all participating countries. The results show that there are substantial differences in working conditions for nurses between the different countries. Some of them were expected (e.g. higher job insecurity in Poland and Slovakia), whilst others seem rather surprising (e.g. the often adverse scores for German and Italian nurses). To increase the mutual understanding of nursing work in Europe and to make this document more informative and lively, we are collecting feedback from key persons within nursing from each participating country. These comments are currently being collected and continuously updated in the internet version of this document. As a result, last week s text version may vary slightly from this one. For reasons of space and comparability, we had to limit the current analysis to registered nurses working in hospitals. At the same time, we are well aware of the increasing importance of the situation in nursing homes and home care in Europe. Additional analyses and documentations of nurses working here are planned. The authors Hans-Martin Hasselhorn Peter Tackenberg Andreas Buescher Michael Simon Angelika Kuemmerling Bernd Hans Mueller University of Wuppertal and University of Witten, Germany 1. Introduction Public and socio-political attention related to nursing often reflects on the following three aspects: i) the working conditions of nurses with its psychological and physical consequences, ii) the structural change of the health care system, and iii) the lack of nursing staff (existing or expected). This is more or less the case for all European countries. Nevertheless substantial differences between the countries do 1

3 exist. In this document we will be focussing on the nursing profession in 1 European countries. For this we will firstly address the above briefly drafted aspects and we will then describe relevant structural aspects of the various health care systems using the data material of the basic inquiry of the European NEXT-Study (Nurses Early Exit Study; We will subsequently analyse key indicators of the work content, the social working environment, the work organisation as well as relevant outcomes such as burnout. A further focus is on the professional perspectives of employees in nursing. More detailed information can be found on the NEXT webpages. 1.1 The shortage of nurses in the context of the structural changes in health care Working conditions in nursing have changed without a doubt. Since the early 8s the health service has had to adapt to the criteria of profitability alongside new management structures more than ever. 1 These developments have been accompanied with increasing case numbers, shorter patient treatment periods 2 and increasing work pressure for employees, nursing staff in particular. This is the case for almost all of Europe. De Troyer has characterised the work of nurses in Europe as underpaid, overworked and under-staffed Lack of nurses When one speaks of a shortage of nurses throughout Europe, one must distinguish between a structural and a real nursing staff shortage. The former refers to when more nurses are required to adequately care for the patients, but no resources (staff vacancies) are available for this. This is the case in East European countries, but also in Spain and at present also in German hospitals. A real shortage (vacancy) exists above all in the UK and in Scandinavia (less so in Finland), as well as in the Netherlands, Belgium and France: here vacancies cannot be filled due to a lack in the supply of nurses Migration The consequence of the real shortage is the migration of nursing staff throughout Europe (in the case of the UK worldwide migration) predominantly in the East-West direction and partly already organised through bilateral contracts such as between Poland and the Netherlands. 3 Moreover, NEXT data indicates that in Eastern Europe many nurses are willing to leave the country in order to continue in the profession abroad. In the NEXT basic assessment (22/23), 21% of all nursing staff in Slovakia and 12% in Poland had considered this step frequently (meaning at least several times per month) (Figure 1). Those considering this were not only younger but also better qualified, tended to be working in hospitals and had less family ties. First reports from the Baltic countries confirm that since they acceded the EU in May 24, particularly young and 2

4 highly qualified health care staff (nurses and physicians) are leaving to work in other European countries, something that is having severe consequences for the local hospitals. 4 Proportion frequently 3 considering 2 working abroad 1 (%) Slovakia (total: 21%) Poland (total: 12%) age groups Figure 1. Proportion of nurses frequently considering working abroad as a nurse (n Poland =433, n Slovakia =3285) Premature departure from the profession We see the main cause of the real shortage in most countries to be the premature departure from the profession. In Germany, this is more pronounced for qualified nursing staff than for other occupational groups: In 22 only 6.2% of qualified nurses were 55 years old and over in comparison to 11.1% for the entire labour force (only women) 4. Many qualified nurses have left the profession long before reaching regular retirement age. The demographic changes will affect the nursing sector in two ways: Firstly the need for nursing will increase due to an increase in the proportion of the elderly in the population: In Germany, it has been estimated that the number of people requiring in- and outpatient care will increase by 37% and 42% respectively from 1998 to Secondly, nursing will require more older nurses than today. 2. NEXT Methodology The NEXT-Study is investigating the reasons, circumstances and consequences surrounding premature departure from the nursing profession. 6,7 The consequences of this step for the person involved as well as for their health care institution and for health care in general are of particular interest here. Its findings will be used when developing target-orientated measures in the design of working conditions with the intent to encourage nurses to stay in their particular field of work. NEXT is being financed by the European Union (QLK6-CT ) and carried out simultaneously in Belgium, Finland, France, Germany, Great Britain, Italy, the Netherlands, Poland, Sweden and Slovakia. The study began in February 22 and has continued until summer 25. More than 4 researchers in 14 research institutions are active members of the NEXT-Study Group. Norwegian researchers have become associated members. The study brings together interdisciplinary expertise from professionals such 3

5 as nurses, nursing scientists, (occupational health) physicians, psychologists, sociologists and statisticians. Within the NEXT-Study five data collection instruments were used: Nursing staff received a questionnaire on their working and living conditions as well as occupational perspectives on two occasions 12 months apart. Nurses who had left their institution during the time of data collection received a further questionnaire to record the reasons, circumstances and consequences of these steps at the time of leaving and 12 months after. Finally, defined organisational parameters and indicators of economic developments were collected for each institution with the use of a checklist (e.g. personnel further education, reorganisation, economic development). 2.1 Participants The subsequent analysis relates to the first data collection wave. Here almost 78, NEXT questionnaires were sent to nursing staff in 585 hospitals, nursing homes and outpatient care services in 1 countries between autumn of 22 and spring ,898 people sent the forms back. This corresponds to a response rate of 51.4%. In order to improve the comparability of this article, only registered nursing staff (those with at least three years of training) in hospitals were chosen (if not otherwise indicated). A total of 25,324 nurses were included in the analysis. Table 1 provides an overview of the participation rate in the NEXT-Study in the individual countries and the case numbers for the analyses in the present inquiry. Country Abbrev. Questionnairenaireponse Question- Res- Cases considered in analyses sent out received rate N Age (%) Mean Std.dev. Belgium BE Germany DE Finland FIN France FR Great Britain UK Italy IT Netherlands NL Norway N Poland PL Slovakia SLK ALL Table 1. Participants of the NEXT-Study in Europe and selection for analyses presented in this report 1 Variables used This frame allows the exemplifying presentation of the results using key indicators for occupational exposure in nursing work as well as for relevant outcomes only. To demonstrate the (sometimes 1 In Norway parts of the NEXT questionnaire (parallel to NEXT-Study) were used in an inquiry of employees in the public service. The data of nursing staff are also being included in these analyses. 4

6 substantially different) structural background of nursing work in the participating countries, we will initially present the following background data: Structural background: age, family situation, working hours. The following variables cover the three relevant areas of occupational exposure: Work content: quantitative demands (scale) Social work environment: social support from colleagues (scale) Work organisation: possibilities for development, influence at work (scale), leadership (scale) and working hours. Finally, the following indicators were selected as outcomes relevant for nursing work: Health: burnout/ exhaustion (scale) Work-health interaction: work ability (index) Occupational mobility: intention to leave the nursing profession. The scales are described by Kuemmerling et al. 8 Further aspects have been assessed using single items. 3. Results 3.1 Structural background The health care systems in Europe vary to some extent substantially in regard to structural aspects, which on its part have an impact on the work load and demands of nurses. In the total NEXT sample, the proportion of registered nurses (including registered old peoples nurses) was 9.4% and was only substantially lower in France (63%) and in Norway (79.1%). In Poland and Slovakia professional care is almost exclusively being carried out by women (only 1.% and 2.3% men, respectively). However, in Italy 25.9% of the participants were men. This was attributed to the high unemployment rates especially in Southern Italy Age distribution The age structure of the nursing population allows both conclusions about occupational mobility (e.g. healthy worker effect) and prognoses concerning future nursing supply. For the ten countries investigated three patterns related to age structure of nursing staff can be seen (Figure 2): In Italy and Poland almost two thirds of nurses were in the 3 to 45 year age group and it is the younger age groups in particular who are weakly represented (pattern 1). A very large proportion of older nurses can be found in Norway and in Finland in particular (pattern 3). All remaining countries had a somewhat better balanced pattern of distribution (pattern 2), yet still characterised by relatively small proportion of younger and above all a low proportion of older nurses. 5

7 proportion of age group in national sample (in %) pattern 1: IT, POL pattern 2: BE, DE, FR, GB, NL, SLK pattern 3: FIN, N age groups (years) Figure 2. Age distribution of participants of the NEXT-Study (all participants, n=39,28). In contrast to previous NEXT data, the following analyses will be restricted to registered nurses in hospitals only Family status Evidently there are large differences in regard to the marital status of nurses in the countries investigated (Figure 3). In Poland and Slovakia the traditional family way of life dominated, each with over two thirds of the respondents living with a partner and children. The German respondents represented by far the other extreme: merely 37.8% lived with partners and children. This however reflects rather the national distribution than typical characteristics of the nursing profession. 1% 8% 6% living... alone 4% 2% % BE DE FIN FR GB IT N NL POL SLK Figure 3. Private living situation of the participants (n=24,914). 6 with partner single parent with children with partner and children Working hours Unconvenient working hours are regarded to be the among most significant work pressures in nursing. Indeed they contribute substantially to the work-family-conflict (above all due to irregularity and strain through overtime 9 ), which in turn has a significant influence on intent to leave the profession (see below).

8 Weekly total working hours (not including overtime compensated with lieu time) fluctuated in the examined countries between 28.1 and 4.1 hours. Part-time work (<35 hours per week) was common in the Netherlands and virtually absent in Slovakia and in Poland (Figure 4). Almost one third of all respondents stated that they often had to work overtime (in Germany and Italy just over 5%). However between 1.1% (the Netherlands) and ca. 16% (Italy, Germany, France) of all questioned considered the strain of working overtime frequently to be highly demanding. 1% 8% 6% weekly working hours (total) 4% below 2 2% % mean BE 33.8 DE 34.3 FIN 37.2 FR 35.9 GB 33.6 IT 36.7 N 31.9 NL 28.1 POL 4.1 SLK and more Figure 4. Working hours of the participants in the NEXT-Study (registered nurses in hospitals, n=24,38). Distribution (staples) and mean total weekly working hours of all participants (bottom line). Not only the length of working hours but also the distribution of working hours has special national characteristics (Figure 5). For example, nurses working night shifts only appear to be common in France, whilst in Italy, Poland and Slovakia night shift is part of rotating shifts. 1% 8% 6% 4% 2% only night shift shift work with nights shift work without nights day work others % BE DE FIN FR IT N NL POL SLK 7 day work regular hours Figure 5. Working hours of the participants in the NEXT-Study (registered nurses in hospitals, n=23,73) Job insecurity In line with Hellgren et al. 1 we have distinguished the term job insecurity in two ways: quantitative and qualitative job insecurity. Quantitative job insecurity refers to the perceived threat through

9 imminent loss of job, whereas qualitative work insecurity stands for the perception of a possible loss of quality within ones current job. Relevant to nurses are here for example undesired internal relocation or receiving an unsuitable shift rota. In regard to quantitative work security the findings are clear and as expected (Figure 6). In Poland and Slovakia more than 4 out of 5 people were worried about becoming unemployed; in the remaining countries this figure was mostly 1% and less, merely Finland was an exception with 17.3%. Worthy of mention is that around every forth questioned in Italy, Germany and Finland estimated it as difficult to get an alternative post in the region as a nurse. This did not appear to be a problem in Belgium, the UK and the Netherlands. 1 9 proportion worried to become unemployed age group BE DE FIN FR GB IT N NL SLK POL Figure 6. Proportion of participants worried about becoming unemployed (registered nurses in hospitals, n=24,97). Respondents felt less secure in regard to the issue of qualitative work insecurity. 41.1% were worried about internal relocation and every second (49.%) about being given an unsuitable shift rota. This was particularly the case in Poland and Slovakia but also in Italy, France and Belgium. 8

10 3.2. Work content We will discuss work content in this article using the example quantitative demands. Quantitative demands refer to the intensity of work ( How much do I have to work per time? ) and explicitly not the length of the working hours. Quantitative demands were highly associated with burnout, job satisfaction and to some degree with intent to leave the profession and general health, but not with sickness absence. The highest means for quantitative demands were found in Poland, Germany, Slovakia and in Finland (Figure 7). In most countries quantitative demands decreased with age, but not in Finland and Germany. In Finland this may be due to the high proportion of older nurses which does not allow the redistribution of heavy work demands to nurses of younger age. In Germany, the high mean scores for quantitative demands among older nurses (both for men and women) may in part be explained by the rather long weekly working hours among nurses aged 5 years and above (36.2 hrs). Among older nurses, quantitative demands increase with increasing weekly working hours. 7 quantitative demands (means, -1) age group BE DE FIN FR GB IT N NL SLK POL Figure 7. Means for quantitative demands by age and country (high scores indicate high quantitative demands; registered nurses in hospitals, n=24,758). 9

11 3.3 Social work environment The social work environment is influencing the perception and the consequences of other psychosocial factors at work. Johnson et al. have shown that low social support at work aggravates the negative influence of job strain (high demands and low decision latitude) on the incidence of cardiovascular diseases 11. As an example for the social work environment we are documenting social support from colleagues. Social support from colleagues was highly correlated with social support from superiors and with quality of leadership. The mean values for social support from colleagues were rather high in all countries and always above those for social support from the superior. Highest scores were found for the Netherlands and the UK and by far the lowest scores were for Italy (Figure 8). Social support from colleagues decreased in all countries with increasing age except in Poland and the UK, where older nurses above 45 years of age had maximum scores. high mean low BE DE FIN FR GB IT NL POL SLK Figure 8. Means for social support from colleagues by country. The error bars show the 99% confidence interval of the mean (high scores indicate high social support from colleagues; registered nurses in hospitals. No data for Norway, n=22,513). 3.4 Work organisation As indicators for work organisation we are considering professional development, influence at work, quality of leadership and satisfaction with working hours. These factors are covering different aspects of work organisation and were only intercorrelated to a low degree (exception: influence at work and quality of leadership) Professional development There were pronounced differences between the participating countries with respect to the mean number of full days off work for further training (Figure 9). To some extent the differences may be accounted for by the fact that in some countries occupational further training for nurses is compulsory in order for them to remain fully eligible to work (UK and France) and to follow the legal demands for 1

12 further education in the course of European adaptation (e.g. academisation of nursing work in Slovakia). In almost all countries both men and full-time employees ( 35 hours per week) took part in more training days than the women and/or part-time employees. As expected, the number of annual training days decreased with increasing age, however not in the two countries with a high proportion of older employees: Finland and Norway; the same applies to Italy, where only relatively fewer older people remain in nursing, possibly those who are particularly committed. In the Netherlands, Poland and Slovakia less than 2% of all respondents took at least one day of training, whilst in Finland, the UK and France in particular more than every second had been absent from work for training for at least one day. 7 mean days absent due to further education age group BE DE FIN FR GB IT N NL SLK POL Figure 9. Mean days absent for further education during the past 12 months by age and country (registered nurses in hospitals, n=22,568) Satisfaction with working hours Working hours as a significant aspect of organisational working conditions differ as shown above considerably between the individual countries. A summarizing indicator of the acceptance of 11

13 the working hours regulations is the question: Are you satisfied with your working hours in regard to your personal well-being? Among the participants selected for this report, satisfaction was relatively high, above all where fewer working hours were worked (Netherlands and Norway) and in the UK (Figure 1). The proportion of nurses satisfied with the working hours was lowest in Poland, Italy, Slovakia and Germany. In all countries except the UK this indicator was u-shaped associated with age and obtained maximum values (highest satisfaction) for the higher age groups. The least satisfied group was found in the group of nurses with day and night shifts (61%), who made up the majority of the group with 6% of the collective. Among those participants only working nights 71% were satisfied with their working hours and for people with regular day work this was 89%. It is interesting that both in the total sample and in most countries the satisfaction with working hours continually increased with the number of children at home (of 68% with no children up to 74% with four and more children). Obviously the employees with children had managed at least to some extent to adapt their working hours to their personal commitments through in particular, fewer working hours or carrying out just night duties more frequently. 1 proportion satisfied with working hours BE DE FIN FR GB IT N NL POL SLK Figure 1. Proportion of nurses satisfied with the working hours in relation to the personal well being by country (registered nurses in hospitals, n=24,626) Quality of leadership In order to measure the quality of leadership on ward level, the ward sisters and their deputies were not considered in the following analyses. In four countries quality of leadership was highly valued and in a further four countries relatively low (Figure 11). Noticeable are the rather high values for Slovakia and Germany (where other aspects of work organisation were often unfavourably estimated) and the low values in Finland and above all in the Netherlands. Possibly this reflects high expectations towards management in these two countries. 12

14 high mean low BE DE FIN FR GB IT NL POL SLK Figure 11. Means for quality of leadership by country. The error bars show the 99% confidence interval of the mean (high scores indicate high quality of leadership; registered nurses in hospitals without ward sister / deputy sister, no data for Norway, n=21,547) Influence at work Influence at work is together with psychological demands one of the central components of the known work-stress model, the demand control model by Karasek 12. Influence at work is associated with physical and psychological health to an even greater extent than psychological demands 13. All in all, the mean scores for influence at work were rather low for the sample investigated (Figure 12). Besides Norway, the Netherlands and the UK had rather high mean scores throughout all age groups. Unexpectedly, scores were low for Finland. The increase with age (which is typical for this scale) was rather small in almost all countries (and widely absent in Germany). Only in Slovakia and Poland the age related increase was steep up to the oldest age group. According to experts from these countries age (and thus work experience) is being respected to a greater extent in working life than in many other European countries. 13

15 7 65 influence at work (means, -1) age group BE DE FIN FR GB IT N NL SLK POL Figure 12. Means for influence at work by age and country (high scores indicate high influence, registered nurses in hospitals, n=25,78). 3.5 Outcomes The consequences of occupational strain were assessed in the NEXT-Study using different indicators of psychological and physical health in order to determine professional future prospects. Burnout (in terms of exhaustion) and work ability will be discussed here alongside the intent to leave the profession Burnout / exhaustion In NEXT, burnout was defined in terms of personal exhaustion. The mean scores for the scale used were rather low. However, already a score of around 5 indicates a severe psychological strain (which was the case for 23% of all participants). The national differences were noticeable: favourable values for Norway and the Netherlands (which also persisted when considering the differences in mean weekly working hours), unfavourable values for France, Slovakia, Belgium and UK (Figure 13). When looking at the total group, the nurses of the age group 3-35 years reported the highest burnout, and young and older nurses lowest burnout. However, the age differences were rather small. In Germany and Italy in particular the burnout means continuously and 14

16 noticeably decreased from the youngest to the oldest age group, and in contrast in Norway and Finland the values in all age groups remained more or less at a constant level. Possibly the findings reflect the different patterns of occupational mobility in these four countries: In Italy and Germany there are strong indications for a healthy worker effect : nurses experiencing much strain may have left the profession, resulting in a smaller proportion of older nurses in the country, but this (selected) group of active nurses tends to be healthier. Norway and Finland on the contrary are as described above countries with a higher proportion of older employees in nursing, where possibilities for premature departure from nursing may be low. 5 4 burnout score (means, -1) age group BE DE FIN FR GB IT N NL SLK POL Figure 13. Means for burnout by age and country (high scores indicate high burnout; registered nurses in hospitals, n=25,362) Work ability The work ability of an individual is made up of several factors which enable a person to carry out a task successfully 14. The individual resources comprise the mental, physical and social prerequisites of the employees as well as their expertise 15 ; factors such as education, training and work experience also play a role 16. In 15

17 addition to the individual resources, the working environment contributes to the work ability of the individual: the psychological, physical and mental working demands as well as the social work environment 15. To assess work ability, Tuomi et al. developed the Work Ability Index (WAI) in the 198s, a questionnaire assessment instrument which covers different aspects of work ability with nine questions and a disease list 17. By adding the obtained points as well as the weighting of single categories for each participant, a WAI score ranging from 7 (total work incapacity) up to 49 (optimal work ability) was calculated, which again can be put into one of the four categories of the work ability index as shown in Figure 14. 1% 8% 6% 4% 2% % BE DE FIN FR GB IT N NL POL SLK work ability category excellent (44-49) good (37-43) moderate (28-36) poor (7-27) Figure 14. Work ability among registered nurses in hospitals in ten countries. Split by categories of work ability (work ability index, WAI) (n=23,4). On average the work ability of Norwegian and Dutch nursing staff was most favourable, which can not be accounted for by less weekly working hours. In all age groups the work ability of Polish, French and German participants was the lowest. Low work ability was clearly associated with the desire to prematurely leave the nursing profession, for younger nurses in terms of a change in profession, for older nurses in terms of early retirement Intent to leave the profession From an occupational and social-political view it is of interest whether and to what extent the drafted aspects of the working conditions in nursing have an effect on professional mobility, i.e. to what extent nurses leave nursing due to certain expositions and/or conditions. At the moment, i.e. after the basic inquiry, it will be investigated in the NEXT-Study to what extent and why nurses contemplate this option. This was carried out with the following question: How often during the past 12 months have you thought of leaving the nursing profession?. For often, we have defined this as considering this at least several times a month, something we believe indicates a serious desire to leave profession. It was by far the nurses in UK who most wanted to leave: Every third respondent considered this often (Figure 15). Italy followed

18 (2.5%) with Germany as a close second (19.%). The lowest proportion of people wanting to leave was in the Netherlands (1.6%), in Poland (11.2%) and in Slovakia (12.4%). When looking at the people willing to leave it is easy to overlook the fact that e.g. in Germany the large majority, namely 81% of all respondents obviously wanted to remain in the profession which means a high commitment to the job remained. 1% 8% "How often do you consider leaving the nursing profession?" 6% 4% 2% % BE DE FIN FR GB IT N NL POL SLK never sometimes/year sometimes/month sometimes/week every day Figure 15. Frequency of registered nurses considering leaving the nursing profession by country. The figures indicate the proportion of those frequently considering this step (registered nurses in hospitals, n=23,778). Predominantly the age group between 25 and 39 years considered professional departure most frequently. Afterwards the preparedness sunk with increasing age, which however did start to increase slightly in the last working years. In all countries except Italy the proportion of those willing to leave was somewhat higher for men than for the women, however often only to a small extent and merely in Germany, Finland and the Netherlands in significant order of size. After depicting who would like to leave the nursing profession we are interested in the reasons for such. Bivariate associations with the desire to leave the occupation and work factors assessed were always clear cut and in the expected direction. At first glance the analyses confirm the causes for occupational departure which have often been assumed: too much to do, too high emotional demands, too low salary, and unfavourable working hours. In multivariate analyses, however, the work-family-conflict and the further development options best account for the intent of nurses to leave nursing in Germany for example. Interestingly this is not only the case in Germany but also in Finland and in France. The NEXT-Study makes it possible to characterise institutions with respect to their psychosocial work environment and to relate this to the intent to leave the nursing profession. 15 German hospitals are participating in the NEXT-Study with between 51 and 439 participants. In Figure 16 the associations between the proportion of participants considering professional departure (Y-axis) and a) quantitative demands, b) the work-family-conflict, c) the quality of leadership and d) the outcome burnout are presented. On the one hand, we found that there were institutions where up to one out of 17

19 three respondents frequently considered professional departure (institution B). On the other hand it becomes obvious that adverse exposure (e.g. higher quantitative demands) in an institution is associated with a higher proportion of nurses wanting to leave the profession. This indicates close associations between enterprise culture and the intent to leave the profession. proportion considering ITL 'often' 6% 5% 4% 3% 2% 1% R B C D E J F L H K G M N O A proportion considering ITL 'often' 6% 5% 4% 3% 2% 1% 3.2 R A 3.4 O 3.6 C D GJ E N H 3.8 B F K L M quantitative demands (range 1-5) work-home conflict (range 1-5) proportion considering ITL 'often' 6% 5% 4% 3% 2% 1% M B C F D G E H K N J L O R A proportion considering ITL 'often' 6% 5% 4% 3% 2% 1% C H D E G N L O A R B J K M F quality of leadership (range 1-5) burnout (range 1-5) Figure 16. Proportion of employees in 15 German hospitals frequently considering leaving the profession, (Y-axis), in relation to a) quantitative demands, b) work family conflict, c) quality of leadership and d) burnout (X-axis) (each letter indicates one hospital). 4. Discussion 4.1 Structural differences in nursing work in Europe The findings presented in this article reveal substantial differences in regard to numerous structural background parameters in the nursing occupation. On the one hand, societal indicators (work place security, marital status) are involved, on the other hand structural factors in work organisation in nursing (e.g. working times). The international benchmarking carried out in the scope of the NEXT-Study will not influence the social general conditions such as job security. But other established differences could raise the question for those responsible as to whether a change of accepted practices could and should be considered. For example, the findings from the Netherlands and Norway suggest that increased 18

20 part-time work in nursing is an option as it in both countries by all means is contributing to the positive findings in regard to working conditions and different outcomes. 4.2 Work content, work organisation and the social work environment When looking at the indicators for work content, -organisation and the social work environment a pattern emerges which is also replicated by further aspects not reported here: we found fortunate indicators for the Netherlands and Norway (see Figure 17). Adverse indicators were more often found for Poland, Slovakia, Italy and Germany. In these four countries adverse exposure is being reflected by different adverse outcomes (see Figure 17). Structure BE DE FIN FR GB IT N NL PL SK Job insecurity Work content Quantitative demands Social work environment Soc. support fr. colleagues Work organisation Professional development Working hours Quality of leadership - Influence at work utcomes Burnout Work ability Intent to leave nursing Figure 17. Comparison of key parameters reported in this manuscript by country. Light spots indicate comparatively fortunate, dark spots adverse conditions. 4.3 Consequences of exposure As indicated in Figure 17, adverse exposure in single countries is often reflected by adverse outcomes. Nurses are sensitive to occupational exposure and have a variety of possibilities to react towards adverse situations. One example for this is the Work Ability Index (WAI). In all age groups, the WAI was lowest in Poland, France and Germany. A detailed analysis of the German scores has shown that it was the estimation of one s own work ability in particular in relation to the perceived demands which led to low mean scores 4. The following example may demonstrate how organisational aspects account for this: If a 55 year old nurse believes that she is not going to be able 19

21 to work in 2 years time, then this does not only reflect her (probably reduced) physical capacities but at least to same degree the (low) willingness of the social work environment to integrate people with reduced capacities in the work process. In countries with a high proportion of older nurses, the scores for this item were much higher. It may be assumed that there, reduced capabilities are not an exclusion criteria for nursing work. Another example is the intent to leave the nursing profession. This is determined by both contextual and structural factors. Our data can not explain why in the UK so many nurses want to leave their profession. According to our findings every third nurse was considering leaving the profession although the ratings for working conditions are rather positive. These findings are in line with another investigation where in the UK high values were found for the question regarding leaving the profession 18. It may be speculated that in the UK prolonged and intensive debates on nursing led to a collective dissatisfaction with the occupational prospects which is however not reflected by the other indicators. This is a different matter in Italy and Germany. Here approximately every fifth nurse has the desire to leave the profession. In both countries intensive discussions are being made in regard to the nursing profession, in Italy in particular in light of the academisation of the nursing profession which is associated with uncertainty for current nurses without academic training. Moreover our findings indicate substantial interpersonal conflicts for nurses in Italy. In Germany numerous indicators of working pressures and demands have been judged unfavourably by the participants, something that is due to the prolonged reorganisation and work intensification in the hospitals. In both countries there was a particularly large proportion of people who felt that they were not being rewarded enough for their work performance 19. The imbalance between efforts and rewards was also pronounced in Poland and Slovakia 19. However, it was not associated with the desire to leave the profession. An important reason for this may be the imminent unemployment situation, which despite extreme unfavourable working conditions and great demands does not allow nurses to leave the profession prematurely - and evidently does not even allow one to consider this. 5. Implications Even though in some European countries and in some areas of health care there is no current real shortage of nurses, demographic development will lead to a shortage of nurses prevailing in the labour market. Until then, the nursing profession will have to be an attractive alternative to other professions. This report documents similarities and fundamental differences of the nursing profession in European countries. We document substantial differences with respect to structural background but also to perceived working conditions and different health and 2

22 behavioural outcomes. These differences show that nursing is possible under different conditions. This observation may stimulate discussions among all stakeholders on national and on European level. The European NEXT-Study Group will contribute to the discussion by continuously providing further research results and proposing implications for all levels involved. References 1 De Troyer, M: The hospital sector in Europe Introductory report. Draft, presentation at Working without limits TUTB-SALTSA Conference, Brussels September 2 2 Arnold, M.; Klauber, J.; Schellschmidt, H. (eds): Krankenhaus-Report 21, Stuttgart New York: Schattauer 21 3 Widerszal-Bazyl, M.; Radkiewicz, P.; Pokorski, J.; Pokorska, J; Ogińska, H.; Pietsch, E.: Who wants to leave nursing in Poland? In: Hasselhorn, H.- M., Tackenberg, P., Müller, B.H. (eds). Working conditions and intent to leave the profession among nursing staff in Europe. Working Life Research Report 7:23. National Institute for Working Life Stockholm 23, S Müller BH, Hasselhorn HM. Arbeitsfähigkeit in der stationären Pflege in Deutschland im europäischen Vergleich. Z Arb Wiss 24;58: Hof, B.: Auswirkungen und Konsequenzen der demographischen Entwicklung für die gesetzliche Kranken- und Pflegeversicherung. Verlag der privaten Krankenversicherung e.v., Köln, 21 6 Hasselhorn, H.M., Tackenberg, P., Müller, B.H. (eds): Working conditions and intent to leave the profession among nursing staff in Europe. Working Life Research Report 7:23. National Institute for Working Life, Stockholm 23 7 Hasselhorn, H.M., Müller, B.H., Tackenberg, P.: Investigating premature departure from the nursing professions in Europe - the European NEXT - Study. In: Hasselhorn, H.M., Tackenberg, P., Müller, B.H. (eds): Working conditions and intent to leave the profession among nursing staff in Europe. Working Life Research Report 7:23 National Institute for Working Life Stockholm 23 ISSN X pp Kuemmerling A, Hasselhorn HM, Tackenberg P. Psychometric properties of the scales used in the NEXT-Study. In: Hasselhorn HM, Tackenberg P, Müller B (eds) Working conditions and intent to leave the profession among nursing staff in Europe. Working Life Research Report 7:23 National Institute for Working Life Stockholm 23 ISSN X pp Simon M, Kuemmerling A, Hasselhorn HM. Work Home Conflict among the European Nursing Profession. Int J Occup Environ Health 24;1: Hellgren, J.; Sverke, M.; Isaksson, K.: A new look at job insecurity and its long-term effects on employee attitudes and well-being. Reports from the Department of Psychology Stockholm University no. 853, Johnson, J.V.; Hall, E.M.; Theorell, T.: Combined effects of job strain and social isolation on cardiovascular disease morbidity and mortality in a random sample of the Swedish male working population. Scand. J. Work Environ. Health 1989;15: Karasek, R.A.: Job demands, job decision latitude, and mental strain: implications for job re-design. Adm Sci Q 1979,24:

23 Kristensen TS. Challenges for research and prevention in relation to work and cardiovascular diseases. Scand J Work Environ Health 1999;25 (6, special issue): Ilmarinen, J., Tempel, J.: Arbeitsfähigkeit 21 Was können wir tun, damit wir gesund bleiben? Hamburg, VSA Verlag 22 Ilmarinen, J.: Ageing workers in the European Union Status and promotion of work ability, employability and employment. Helsinki: Finnish Institute of Occupational Health 1999 Camerino, D., van der Heijden, B., Estryn-Behar, M., Kiss, P., Hasselhorn, H- M.: Work ability in the nursing profession. In: Hasselhorn, H.-M., Tackenberg, P., Müller, B.H. (Eds) Working conditions and intent to leave the profession among nursing staff in Europe. Working Life Research Report 7:23. National Institute for Working Life, Stockholm S Tuomi, K., Ilmarinen, J., Jahkola, A., Katajarinne, L., Tulkki, A.: Work ability Index (2nd ed.). Helsinki: Finnish Institute of Occupational Health 1998 Linda Aiken, Presentation at the ambassy of the United States of America in Brussels, May 24 Hasselhorn HM, Tackenberg P, Peter R and the NEXT-Study Group. Effort-reward-imbalance among nurses in stable countries and in countries in transition. Int J Occup Environ Health 24;1: