According to most experts, the U.S. faces a growing shortage of registered nurses, threatening the quality of care hospitals can provide. In the setting of nurse shortages and simultaneous concern about patient safety, nurses’ job satisfaction and their assessment of quality of care become critical. This Issue Brief highlights a crossnational survey that describes nurses’ perceptions of their hospital work environment, and identifies core problems in work design and workforce management in five countries

Aiken, Linda H

Clarke, Sean P

Sloane, Douglas M

Sochalski, Julie

English

Kosmopolis

University of Pennsylvania
ScholarlyCommons
Issue Briefs Leonard Davis Institute of Health Economics
5-22-2001
Cause for Concern: Nurses’ Reports of Hospital
Care in Five Countries
Linda H. Aiken
Sean P. Clarke
Douglas M. Sloane
Julie Sochalski
Follow this and additional works at: http://repository.upenn.edu/ldi_issuebriefs
This paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/21
For more information, please contact repository@pobox.upenn.edu.
Aiken, Linda H.; Clarke, Sean P.; Sloane, Douglas M.; and Sochalski, Julie. Cause for Concern: Nurses’ Reports of Hospital Care in
Five Countries. LDI Issue Briefs. 2001; 6 (8). http://ldi.upenn.edu/policy/issue-briefs/2001/05/22/cause-for-concern-nurses-
reports-of-hospital-care-in-five-countries
Cause for Concern: Nurses’ Reports of Hospital Care in Five Countries
Abstract
According to most experts, the U.S. faces a growing shortage of registered nurses, threatening the quality of
care hospitals can provide. In the setting of nurse shortages and simultaneous concern about patient safety,
nurses’ job satisfaction and their assessment of quality of care become critical. This Issue Brief highlights a
crossnational survey that describes nurses’ perceptions of their hospital work environment, and identifies core
problems in work design and workforce management in five countries.
License
This work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.
This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/21
Leonard Davis Institute of Health Economics
LDI Issue Brief
Volume 6, Number 8
May 2001
Linda H. Aiken, PhD, RN
LDI Senior Fellow
Sean P. Clarke, PhD, RN
Douglas M. Sloane, PhD
Julie Sochalski. PhD, RN
LDI Senior Fellow
Center for Health Outcomes and
Policy Research, School of Nursing,
University of Pennsylvania
In U.S., hospital
reorganization has
changed nurses’ work
environment
Cause for Concern: Nurses’ Reports of
Hospital Care in Five Countries
Editor’s Note:  According to most experts, the U.S. faces a growing shortage of registered
nurses, threatening the quality of care hospitals can provide.  In the setting of nurse
shortages and simultaneous concern about patient safety, nurses’ job satisfaction and
their assessment of quality of care become critical.  This Issue Brief highlights a cross-
national survey that describes nurses’ perceptions of their hospital work environment,
and identifies core problems in work design and workforce management in five
countries.
The past decade has witnessed pronounced changes in the organization of U.S. hospitals,
many the direct result of restructuring and reengineering initiatives intended to decrease
costs and increase productivity.  In a recent article, Aiken and colleagues described
initiatives that hospitals undertook from 1986 to 1998, and examined changes in
nursing practice environments.
• In a recent national survey, 57% of hospital chief executive officers reported that their
hospitals had undergone restructuring. Personnel were reduced in about 90% of
restructured hospitals. Skill mix reductions (i.e., declines in the proportions of
registered nurses on unit staffs) occurred in about 70% of the restructured hospitals.
• Drawing upon their studies of hospitals over time, the authors found that the nurse
practice environment in hospitals has deteriorated. Hospitals are now less likely to
have enough registered nurses, adequate support services, supervisors who are
supportive of nursing, an influential chief nurse executive, and other organizational
characteristics associated with nurse satisfaction.
• Inadequate nurse staffing and uneven quality of care in U.S. hospitals is often blamed
on the growth of managed care, reductions in Medicare payments to hospitals, or
other factors unique to the U.S. However, news reports indicate that Canada and the
United Kingdom face remarkably similar problems of nurse shortages and
discontented nurses.
To provide an international perspective on the changing hospital work environment,
Aiken and colleagues surveyed 43,329 nurses from the U.S., Canada, England, Scotland,
and Germany working in more than 700 hospitals in 1998 and 1999.
 • The study was conducted by the International Outcomes Research Consortium,
which consists of seven interdisciplinary research teams in participating countries lead
Survey explores hospital
organizational climate,
nurse staffing in five
countries
Low morale among nurses
is widespread and not
unique to the United
States
Nurses point to problems
in hospital staffing,
management
by the University of Pennsylvania’s School of Nursing. The U.S. sample included all
hospitals in Pennsylvania; the Canadian sample included all hospitals in Ontario,
Alberta, and British Columbia; the Scottish sample included all hospital trusts; the
English and German samples included all hospitals participating in benchmarking
organizations.
• All nurses in the study received self-administered questionnaires that they returned
anonymously by mail. Response rates ranged from 42% to 53% across geographic
regions.
• The age distribution of responding nurses is consistent with reports of an aging nurse
workforce in the North American countries. In the U.S. and Canada, the percentages
of hospital nurses under age 30 (and therefore having the potential for extended
careers in nursing) was quite low—19% and 10% respectively.  In the Western
European countries, between 32% and 41% of responding nurses were under 30.
Nurses’ job dissatisfaction and levels of burnout limit adequate staffing, and may reduce
quality of care and threaten patient outcomes.
• In the U.S., more than 40% of nurses working in hospitals reported being dissatisfied
with their jobs. Job dissatisfaction among nurses, at least in the U.S., is 3-4 times
higher than that of other professionals or the average worker.  In Canada and the
United Kingdom, 33%-38% of nurses were also dissatisfied.  In Germany, 17% of
nurses reported dissatisfaction with their positions.
• Significant numbers of nurses across countries are experiencing job-related strain.  In
all countries except for Germany, 30%-40% of nurses had higher “burnout” scores
than other medical workers, as measured by a standardized instrument.
• More than three in ten nurses in England and Scotland, and two in ten in the U.S.,
plan to leave their hospital jobs within the next year. Strikingly, among nurses under
30, about half plan to leave in the United Kingdom, and one-third plan to leave in
the U.S.
Although discontent among hospital nurses is high, the nurses surveyed did not perceive
all aspects of hospital practice as unsatisfactory. The greatest concerns center around
staffing adequacy and management policies.
• A vast majority believe that they work with physicians and other nurses who provide
high-quality care.  More than 80% of respondents in each country felt that physicians
and nurses have good working relationships in hospitals.
• Only 30%-40% of respondents reported that there are enough registered nurses to
provide high quality care and enough staff to get work done.
• Fewer than half of nurses in each country reported that hospital management is
responsive to their concerns, or provide opportunities for nurses to participate in
decision making.
• Fewer than 25% of nurses in the United Kingdom felt that their salaries are adequate,
compared to 41% in Germany, 57% in the U.S., and 69% in Canada. In the U.S.
and Canada at least, nurses are more likely to be dissatisfied with working conditions
than with their wages.
U.S. and Canadian nurses
report greater workloads,
more time spent on non-
nursing tasks in past year
Responses to a series of questions addressing changes in workload, tasks, and structure of
nursing management reveal that nurses are feeling the effects of hospital restructuring in
the U.S. and Canada. These questions were not included in the United Kingdom
surveys.
• 83% of nurses in the U.S. and 64% in Canada reported that the number of patients
assigned to them had increased in the past year.  In contrast, 44% of German nurses
reported an increased workload.
• Nearly 60% of U.S. nurses reported a decrease in nurse-manager positions in their
hospitals.  This finding implies that in addition to having responsibility for more
patients, staff nurses might also have greater responsibilities for managing services and
personnel at the unit level.
• When asked about the kinds of tasks performed on their last shift, many nurses across
countries reported spending time on non-nursing tasks (such as transporting patients,
delivering or retrieving food trays, and housekeeping activities), while care requiring
their professional skills (such as pain control, oral hygiene, skin care, or teaching
patients and family) were left undone.
Respondents, particularly in North America, voice concerns about the deteriorating
quality of care in their hospitals, and the frequency of specific events that indicate
problems in patient safety.
• Only one of nine nurses in Germany, and one in three nurses in other countries, rated
the quality of nursing care on their units as excellent.
• In the U.S. and Canada, only about one-third of nurses were confident that their
patients were adequately prepared to manage at home upon discharge. Western
European nurses had relatively positive ratings of their patients’ preparedness for
discharge, which might be attributable to longer hospital stays as well as more
extensive home care services in those countries.
• Nearly half of the nurses in the U.S. and Canada believed that quality of care at their
hospital had deteriorated in the past year. Deterioration of quality of care was
reported less often in European countries than in North America, which may reflect
poorly on the extensive restructuring of Canadian and U.S. hospitals in the years
prior to the survey.
• In general, U.S. and Canadian nurses were more likely than German nurses to report
that incidents such as medication errors and patient falls with injuries occur with
regularity.
Nurses in countries with distinctly different health care systems report similar
shortcomings in their work environments and the quality of hospital care.
• The current shortage of hospital nurses in Western countries appears destined to
worsen over the long term, with nurses’ job dissatisfaction and intention to leave at
high levels, an aging workforce, and a substantial percentage of young nurses
intending to leave their hospital jobs.
Nurses report deteriorating
quality of care in U.S. and
Canadian hospitals
POLICY IMPLICATIONS
Continued on back.
Nonprofit Organization
U.S. Postage
P  A  I  D
Permit No. 2563
Philadelphia, PA 19104
Issue Brief
Published by the
Leonard Davis Institute
of Health Economics
University of Pennsylvania
3641 Locust Walk
Philadelphia, PA 19104-6218
215.898.5611
fax 215.898.0229
ADDRESS CORRECTION REQUESTED
• Hospital restructuring and “reengineering” were designed to emulate industrial
models of productivity improvement, rather than to address nurses’ concerns.  These
approaches have had limited success in retaining nurses or improving patient
outcomes, and in some cases, they have yielded negative outcomes.
• To retain qualified nurses, hospitals will have to develop personnel policies and
benefits comparable to those in other lines of work, including opportunities for
advancement, lifelong learning, flexible work schedules, and policies that promote
institutional loyalty and retention.  Popular short-term strategies such as signing
bonuses and use of temporary personnel do not address the issues at their core.
• The problems reflected in work design and workforce management contribute to
uneven quality of care, medical errors, and adverse patient outcomes.  Ongoing work
by this international consortium is using data on hospital characteristics and patient
discharges to refine more clearly the relationship among nurse staffing, nurse
organization, and patient outcomes.
POLICY IMPLICATIONS
Continued
This Issue Brief is based on the following articles: L.H. Aiken, S.P. Clarke, D.M. Sloane, J.A. Sochalski, R. Busse, H. Clarke, P.
Giovannetti, J. Hunt, A. M. Rafferty, and J. Shamian.  Nurses’ Reports on Hospital Care in Five Countries.  Health Affairs, May/June
2001, vol. 20, pp. 43-53; and L.H. Aiken, S.P. Clarke, and D.M. Sloane.  Hospital Restructuring: Does It Adversely Affect Care and
Outcomes?  Journal of Nursing Administration, October 2000, vol. 30, pp. 457-465.
Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA
19104-6218, 215-898-5611.
Janet Weiner, MPH, Associate Director for Health Policy, Editor
David A. Asch, MD, MBA, Executive Director
Issue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, and
social and ethical issues that influence how health care is organized, financed, managed, and delivered in the United States and
internationally. The LDI is a cooperative venture among Penn schools including Dental Medicine, Medicine, Nursing and Wharton. For
additional information on this or other Issue Briefs, contact Janet Weiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).
Visit us on the web at www.upenn.edu/ldi


Cause for Concern: Nurses’ Reports of Hospital Care in Five Countries

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics5-22-2001Cause for Concern: Nurses’ Reports of HospitalCare in Five CountriesLinda H. AikenSean P. ClarkeDouglas M. SloaneJulie SochalskiFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/21For more information, please contact repository@pobox.upenn.edu.Aiken, Linda H.; Clarke, Sean P.; Sloane, Douglas M.; and Sochalski, Julie. Cause for Concern: Nurses’ Reports of Hospital Care inFive Countries. LDI Issue Briefs. 2001; 6 (8). http://ldi.upenn.edu/policy/issue-briefs/2001/05/22/cause-for-concern-nurses-reports-of-hospital-care-in-five-countriesCause for Concern: Nurses’ Reports of Hospital Care in Five CountriesAbstractAccording to most experts, the U.S. faces a growing shortage of registered nurses, threatening the quality ofcare hospitals can provide. In the setting of nurse shortages and simultaneous concern about patient safety,nurses’ job satisfaction and their assessment of quality of care become critical. This Issue Brief highlights acrossnational survey that describes nurses’ perceptions of their hospital work environment, and identifies coreproblems in work design and workforce management in five countries.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/21Leonard Davis Institute of Health EconomicsLDI Issue BriefVolume 6, Number 8May 2001Linda H. Aiken, PhD, RNLDI Senior FellowSean P. Clarke, PhD, RNDouglas M. Sloane, PhDJulie Sochalski. PhD, RNLDI Senior FellowCenter for Health Outcomes andPolicy Research, School of Nursing,University of PennsylvaniaIn U.S., hospitalreorganization haschanged nurses’ workenvironmentCause for Concern: Nurses’ Reports ofHospital Care in Five CountriesEditor’s Note:  According to most experts, the U.S. faces a growing shortage of registerednurses, threatening the quality of care hospitals can provide.  In the setting of nurseshortages and simultaneous concern about patient safety, nurses’ job satisfaction andtheir assessment of quality of care become critical.  This Issue Brief highlights a cross-national survey that describes nurses’ perceptions of their hospital work environment,and identifies core problems in work design and workforce management in fivecountries.The past decade has witnessed pronounced changes in the organization of U.S. hospitals,many the direct result of restructuring and reengineering initiatives intended to decreasecosts and increase productivity.  In a recent article, Aiken and colleagues describedinitiatives that hospitals undertook from 1986 to 1998, and examined changes innursing practice environments.• In a recent national survey, 57% of hospital chief executive officers reported that theirhospitals had undergone restructuring. Personnel were reduced in about 90% ofrestructured hospitals. Skill mix reductions (i.e., declines in the proportions ofregistered nurses on unit staffs) occurred in about 70% of the restructured hospitals.• Drawing upon their studies of hospitals over time, the authors found that the nursepractice environment in hospitals has deteriorated. Hospitals are now less likely tohave enough registered nurses, adequate support services, supervisors who aresupportive of nursing, an influential chief nurse executive, and other organizationalcharacteristics associated with nurse satisfaction.• Inadequate nurse staffing and uneven quality of care in U.S. hospitals is often blamedon the growth of managed care, reductions in Medicare payments to hospitals, orother factors unique to the U.S. However, news reports indicate that Canada and theUnited Kingdom face remarkably similar problems of nurse shortages anddiscontented nurses.To provide an international perspective on the changing hospital work environment,Aiken and colleagues surveyed 43,329 nurses from the U.S., Canada, England, Scotland,and Germany working in more than 700 hospitals in 1998 and 1999. • The study was conducted by the International Outcomes Research Consortium,which consists of seven interdisciplinary research teams in participating countries leadSurvey explores hospitalorganizational climate,nurse staffing in fivecountriesLow morale among nursesis widespread and notunique to the UnitedStatesNurses point to problemsin hospital staffing,managementby the University of Pennsylvania’s School of Nursing. The U.S. sample included allhospitals in Pennsylvania; the Canadian sample included all hospitals in Ontario,Alberta, and British Columbia; the Scottish sample included all hospital trusts; theEnglish and German samples included all hospitals participating in benchmarkingorganizations.• All nurses in the study received self-administered questionnaires that they returnedanonymously by mail. Response rates ranged from 42% to 53% across geographicregions.• The age distribution of responding nurses is consistent with reports of an aging nurseworkforce in the North American countries. In the U.S. and Canada, the percentagesof hospital nurses under age 30 (and therefore having the potential for extendedcareers in nursing) was quite low—19% and 10% respectively.  In the WesternEuropean countries, between 32% and 41% of responding nurses were under 30.Nurses’ job dissatisfaction and levels of burnout limit adequate staffing, and may reducequality of care and threaten patient outcomes.• In the U.S., more than 40% of nurses working in hospitals reported being dissatisfiedwith their jobs. Job dissatisfaction among nurses, at least in the U.S., is 3-4 timeshigher than that of other professionals or the average worker.  In Canada and theUnited Kingdom, 33%-38% of nurses were also dissatisfied.  In Germany, 17% ofnurses reported dissatisfaction with their positions.• Significant numbers of nurses across countries are experiencing job-related strain.  Inall countries except for Germany, 30%-40% of nurses had higher “burnout” scoresthan other medical workers, as measured by a standardized instrument.• More than three in ten nurses in England and Scotland, and two in ten in the U.S.,plan to leave their hospital jobs within the next year. Strikingly, among nurses under30, about half plan to leave in the United Kingdom, and one-third plan to leave inthe U.S.Although discontent among hospital nurses is high, the nurses surveyed did not perceiveall aspects of hospital practice as unsatisfactory. The greatest concerns center aroundstaffing adequacy and management policies.• A vast majority believe that they work with physicians and other nurses who providehigh-quality care.  More than 80% of respondents in each country felt that physiciansand nurses have good working relationships in hospitals.• Only 30%-40% of respondents reported that there are enough registered nurses toprovide high quality care and enough staff to get work done.• Fewer than half of nurses in each country reported that hospital management isresponsive to their concerns, or provide opportunities for nurses to participate indecision making.• Fewer than 25% of nurses in the United Kingdom felt that their salaries are adequate,compared to 41% in Germany, 57% in the U.S., and 69% in Canada. In the U.S.and Canada at least, nurses are more likely to be dissatisfied with working conditionsthan with their wages.U.S. and Canadian nursesreport greater workloads,more time spent on non-nursing tasks in past yearResponses to a series of questions addressing changes in workload, tasks, and structure ofnursing management reveal that nurses are feeling the effects of hospital restructuring inthe U.S. and Canada. These questions were not included in the United Kingdomsurveys.• 83% of nurses in the U.S. and 64% in Canada reported that the number of patientsassigned to them had increased in the past year.  In contrast, 44% of German nursesreported an increased workload.• Nearly 60% of U.S. nurses reported a decrease in nurse-manager positions in theirhospitals.  This finding implies that in addition to having responsibility for morepatients, staff nurses might also have greater responsibilities for managing services andpersonnel at the unit level.• When asked about the kinds of tasks performed on their last shift, many nurses acrosscountries reported spending time on non-nursing tasks (such as transporting patients,delivering or retrieving food trays, and housekeeping activities), while care requiringtheir professional skills (such as pain control, oral hygiene, skin care, or teachingpatients and family) were left undone.Respondents, particularly in North America, voice concerns about the deterioratingquality of care in their hospitals, and the frequency of specific events that indicateproblems in patient safety.• Only one of nine nurses in Germany, and one in three nurses in other countries, ratedthe quality of nursing care on their units as excellent.• In the U.S. and Canada, only about one-third of nurses were confident that theirpatients were adequately prepared to manage at home upon discharge. WesternEuropean nurses had relatively positive ratings of their patients’ preparedness fordischarge, which might be attributable to longer hospital stays as well as moreextensive home care services in those countries.• Nearly half of the nurses in the U.S. and Canada believed that quality of care at theirhospital had deteriorated in the past year. Deterioration of quality of care wasreported less often in European countries than in North America, which may reflectpoorly on the extensive restructuring of Canadian and U.S. hospitals in the yearsprior to the survey.• In general, U.S. and Canadian nurses were more likely than German nurses to reportthat incidents such as medication errors and patient falls with injuries occur withregularity.Nurses in countries with distinctly different health care systems report similarshortcomings in their work environments and the quality of hospital care.• The current shortage of hospital nurses in Western countries appears destined toworsen over the long term, with nurses’ job dissatisfaction and intention to leave athigh levels, an aging workforce, and a substantial percentage of young nursesintending to leave their hospital jobs.Nurses report deterioratingquality of care in U.S. andCanadian hospitalsPOLICY IMPLICATIONSContinued on back.Nonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue Brief Published by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTED• Hospital restructuring and “reengineering” were designed to emulate industrialmodels of productivity improvement, rather than to address nurses’ concerns.  Theseapproaches have had limited success in retaining nurses or improving patientoutcomes, and in some cases, they have yielded negative outcomes.• To retain qualified nurses, hospitals will have to develop personnel policies andbenefits comparable to those in other lines of work, including opportunities foradvancement, lifelong learning, flexible work schedules, and policies that promoteinstitutional loyalty and retention.  Popular short-term strategies such as signingbonuses and use of temporary personnel do not address the issues at their core.• The problems reflected in work design and workforce management contribute touneven quality of care, medical errors, and adverse patient outcomes.  Ongoing workby this international consortium is using data on hospital characteristics and patientdischarges to refine more clearly the relationship among nurse staffing, nurseorganization, and patient outcomes.POLICY IMPLICATIONSContinuedThis Issue Brief is based on the following articles: L.H. Aiken, S.P. Clarke, D.M. Sloane, J.A. Sochalski, R. Busse, H. Clarke, P.Giovannetti, J. Hunt, A. M. Rafferty, and J. Shamian.  Nurses’ Reports on Hospital Care in Five Countries.  Health Affairs, May/June2001, vol. 20, pp. 43-53; and L.H. Aiken, S.P. Clarke, and D.M. Sloane.  Hospital Restructuring: Does It Adversely Affect Care andOutcomes?  Journal of Nursing Administration, October 2000, vol. 30, pp. 457-465.Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA19104-6218, 215-898-5611.Janet Weiner, MPH, Associate Director for Health Policy, EditorDavid A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, andsocial and ethical issues that influence how health care is organized, financed, managed, and delivered in the United States andinternationally. The LDI is a cooperative venture among Penn schools including Dental Medicine, Medicine, Nursing and Wharton. Foradditional information on this or other Issue Briefs, contact Janet Weiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).Visit us on the web at www.upenn.edu/ldi

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Cause for Concern: Nurses’ Reports of Hospital Care in Five Countries

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