Nurses’ intention to leave their profession: A cross sectional observational study in 10 European countries

International Journal of Nursing Studies 50 (2013) 174–184

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Nurses’ intention to leave their profession: A cross sectional observational study in 10 European countries Maud M. Heinen a,1,*, Theo van Achterberg a,1, Rene´ Schwendimann b,1, Britta Zander c,1, Anne Matthews d,1, Maria Ko´zka e,1, Anneli Ensio f,1, Ingeborg Strømseng Sjetne g,1, Teresa Moreno Casbas h,1, Jane Ball i,1, Lisette Schoonhoven a,j,1 a

Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Institute of Nursing Science, Faculty of Medicine, University of Basel, Switzerland Department of Health Care Management, WHO Collaborating Centre for Health Systems Research and Management, Technical University Berlin, Germany d School of Nursing, Dublin City University, Dublin, Ireland e Department of Internal Diseases and Community Nursing, Jagiellonian University Medical College, Krakow, Poland f University of Eastern Finland, Finland g The Norwegian Knowledge Centre for the Health Services, Oslo, Norway h Nursing and Healthcare Research Unit (Investe´n-isciii), Madrid, Spain i National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, King’s College London, London, United Kingdom j Faculty of Health Sciences, University of Southampton, United Kingdom b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 23 March 2012 Received in revised form 25 September 2012 Accepted 30 September 2012

Background: As the European population ages, the demand for nursing care increases. Yet, a shortage of nurses at the labour market exists or is predicted for most European countries. There are no adequate solutions for this shortage yet, and recruitment of future nurses is difficult. Therefore, retaining nurses for the profession is urgent. Objective: To determine factors associated with nurses’ intention to leave the profession across European countries. Design: A multi-country, multi-centre, cross-sectional analysis of survey data. Setting: 2025 surgical and medical units from 385 hospitals in ten European countries that participated in the RN4Cast study. Hospital selection was based on a stratified randomised selection procedure. Participants: All nurses from the participating medical and surgical hospital wards received a survey. 23,159 nurses (64%) returned the survey. Methods: The nurse survey included questions about intention to leave the profession, nurse characteristics, factors related to work environment, patient-to-nurse staffing ratio, burnout and perceived quality and safety of care. Multilevel regression analyses with ‘intention to leave the profession’ as dependent variable were conducted for all 10 countries combined as well as per country. Results: Overall, 9% of the nurses intended to leave their profession. This varied from 5 to 17% between countries. Seven factors were associated with intention to leave the profession at European level: nurse–physician relationship (OR 0.86; 95%CI 0.79–0.93), leadership (OR 0.78; 95% CI 0.70–0.86), participation in hospital affairs (0.68; 95%CI 0.61– 0.76), older age (OR 1.13; 95%CI 1.07–1.20), female gender (OR 0.67; 95%CI 0.55–0.80), working fulltime (OR 0.76; 95%CI 0.66–0.86) and burnout (OR 2.02; 95%CI 1.91–2.14). The relevance of these factors differed for the individual countries. Nurse perceived staffing

Keywords: Burnout Hospital Intention to leave Nursing staff Work environment

* Corresponding author. Tel.: +31 24 3668198; fax: +31 24 3540166. E-mail address: [email protected] (M.M. Heinen). 1 For the RN4Cast consortium, see Appendix A. 0020-7489/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2012.09.019

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adequacy, patient-to-nurse staffing ratio, perceived quality and safety of care and hospital size were not associated with intention to leave at a European level. Conclusion: Burnout is consistently associated with nurses’ intention to leave their profession across the 10 European countries. Elements of work environment are associated with intention to leave the nursing profession but differ between countries, indicating the importance of national contexts in explaining and preventing nurses’ intention to leave their profession. ß 2012 Elsevier Ltd. All rights reserved.

What is already known about the topic?  The evidence on factors associated with intention to leave the nursing profession is limited.  Burnout seems to be associated with a higher risk of intention to leave.  A supportive work environment is expected to prevent intention to leave the profession as well as actual leaving. What this paper adds  At a European level as well as for the separate countries several elements of nurses’ work environment are significantly related to intention to leave the profession.  At a European level, males, older nurses and nurses with part-time positions are more likely to consider leaving their profession, although these results are less consistent across countries.  Burnout is consistently associated with nurses’ intention to leave their profession across European countries. 1. Introduction As the European population ages, the demand for nursing care increases. Yet, a shortage of nurses at the labour market either exists or is predicted for most European countries (Hasselhorn et al., 2003; Simoens, 2005; Vernooij-Dasssen et al., 2009). Whereas the use of technology could increase optimal use of nurses’ time to some extent, it is unlikely to resolve the issue (VernooijDasssen et al., 2009). Migration of health professionals across countries, attracting young people to join the nursing workforce and retention of existing staff are three possible approaches to tackle current and future nurse shortages. In theory, migration of nurses across European countries could lead to efficient employment of nurses where they are most needed. In practice however, migration across European states is often hindered by language and cultural barriers as well as qualification and social security issues (de Veer et al., 2004). Moreover, migration of nurses often comes with an exodus of nurses from low income countries, thus relocating rather than solving problems (Lesniowska, 2008). Educating and recruiting more future professionals for nursing requires time and attention, but is crucial with a view to the future. Yet, nursing is often perceived as not very appealing as well as underpaid (Coombs et al., 2003). While recruitment is somewhat easier in times of economic recession, fewer young people are available

for the labour market, thus stressing the need for retention of nurses for the profession. Nurses’ intention to leave their job has been the focus of many studies and publications, as these intentions could be potentially influenced by nurse managers and health care organisations in order to prevent actual leave. Apart from age, many potentially modifiable factors such as workload, burnout and quality of care at the workplace have often been reported as important predictors of nurses’ intention to leave their job (Aiken et al., 2002; Estryn-Behar et al., 2010; van Bogaert et al., 2009; van der Heijden et al., 2010). Furthermore, evidence shows that early signs of departure are strong predictors of the actual behaviour (Murrells et al., 2008). Whereas many studies addressed intention to leave the current job or employer, fewer studies looked into intention to leave the nursing profession (Hayes et al., 2006). While changing jobs might be beneficial to individual nurses or even the nursing profession at large, leaving the profession is necessarily problematic in the light of societal investment in training and existing shortages. Disentangling reasons behind job changes within nursing vs. reasons for leaving the profession is crucial in order to determine and develop adequate interventions for nurse retention for the current employer as well as for the profession. In an integrative review, Flinkman et al. (2010) included 31 international empirical studies to address nurses’ intention to leave the profession. The proportion of nurses who intended to leave their profession varied from 4% to 54%, although large variations in the definition of ‘intention to leave’ could account for this variability. In several studies, male, younger and more qualified nurses were more likely to leave the profession. Evidence for negative effects of low commitment to the profession, as well as dissatisfaction with job content, salaries or possibilities for development was also identified. Furthermore, burnout, stress, work–family conflicts and having a family situation where the nurses’ income was not essential also correlated to a higher intention to leave. A main conclusion from the review by Flinkman et al. (2010) however, relates to the many limitations of primary studies in this area, thus indicating the need for more rigorous studies in order to arrive at more exact estimates and confirm findings on factors related to intention to leave the profession. We present data from the RN4CAST study, a study in various European countries, which provided data on intention to leave the nursing profession due to job dissatisfaction and data on potentially related factors (Sermeus et al., 2011). Previously, Aiken et al. (2012)

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reported effects of work environment and staffing ratio on intention to leave the current job based on RN4CAST data. 1.1. Objectives This study investigated factors associated with intention to leave the profession due to job dissatisfaction of hospital-based nurses in 10 European countries. The following research questions were formulated: 1. Which characteristics of nurses and their work environment are associated with nurses’ intention to leave the profession across European countries? 2. Do these associations differ between European countries? 2. Methods 2.1. Design The study had a multi-country, multicentre, cross sectional observational design. 2.2. Setting and participants Data from 10 European countries participating in the RN4CAST study were used to establish related factors to intention to leave the profession (Sermeus et al., 2011). These countries were Belgium, Finland, Germany, Ireland, the Netherlands, Norway, Poland, Spain, Switzerland and the United Kingdom. The RN4CAST project also included data from Sweden and Greece. These data were not used in this study on intention to leave the profession however, as they did not allow for the clustering respondents at ward level in the analysis. Each country aimed to include at least 20 hospitals in the study, with at least four care units in each hospital. Selection of hospitals was based on a stratified randomised selection procedure, to ensure a representative sample with regard to geographical site and hospital size. Within the hospitals, surgical and medical units for adult patients were included, excluding units with highly specialised care such as critical care units or emergency care departments. Nurses were invited to participate by their department chief nurses and/or ward managers. All nurses received a survey accompanied by a letter in which the purpose of the study was explained. Nurses were asked to return the survey anonymously in a drop box on the ward or by using pre-addressed envelopes. Participation was voluntary, filling in the questionnaire was considered as informed consent. The survey instruments were translated into various languages following a rigorous procedure including forward and backward translation (Squires et al., 2012). 2.3. Variables and measurement Study key variables were: Intention to leave the nursing profession, work environment, hospital size, patient to nurse staffing ratio, levels of burnout and perceived quality and safety of care.

Nurses’ intention to leave the profession was established by two questions. In the first question nurses were asked if they intended to leave their job in the next year due to job dissatisfaction. If they answered this question in the affirmative, they were asked to differentiate between leaving the hospital and leaving the profession. Nurse work environment was measured using the Practice Environment Scale of the Nursing Work Index Revised (PES-NWI) (Aiken and Patrician, 2000). The revised PES-NWI consists of 32 positive statements about the work environment to which the respondents declare varying degrees of agreement (‘‘strongly disagree’’, ‘‘disagree’’, ‘‘agree’’, ‘‘strongly agree’’). A global composite score can be constructed by calculating the mean across all the 32 items. Five subscales have been identified among the 32 items, which cover perceived staffing adequacy, nurse– physician relationship, leadership, Nurse Foundations for Quality of Care (especially in relation to staff development and quality management) and participation in hospital affairs. A mean score was calculated for each of the PESNWI subscales, and a high score represents a favourable description of that particular aspect of their work environment. Internationally both the overall work environment score as a single measure and its subscales are used (Warshawsky and Havens, 2011). As information on PES-NWI subscales is more informative in exploring the dynamics of intention to leave the profession than using PES-NWI total scores, we chose to use PES-NWI subscales in the primary analysis. We conducted secondary analysis with the composite score for the whole PES-NWI. The patient to nurse staffing ratio was calculated by dividing the number of patients by the number of nurses during the nurses’ last shift, which could have been any possible shift. The staffing ratio variable used in the statistical model was calculated on the unit level. Nurse burnout was measured using the Emotional Exhaustion subscale of the Maslach Burnout Inventory, hereafter referred to as ‘Burnout’ (Maslach, 1996). Perception of Quality of Care was established by means of a single question: ‘In general, how would you describe the quality of nursing care delivered to patients on your unit/ ward?’ They could answer this question on a four point answering scale with ‘poor’, ‘fair’, ‘good’ or ‘excellent’. Perception of Patient Safety was assessed by using a five point scale item from the AHRQ Hospital Survey on Patient Safety Culture. Nurses were asked to ‘please give your unit/ ward an overall grade on patient safety’, using ‘failing’, ‘poor’, ‘acceptable’, ‘very good’ and ‘excellent’ as answering categories. The nurse characteristics age, gender, educational level, and working full-time or part-time were also established through this questionnaire. Educational level was defined as either bachelor or diploma training level. Finally, hospital size was defined as small, medium or large, based on the number of beds. Ethical issues: The project has been granted financial support from the European commission. Depending on national legislation, the study protocol was approved by either central ethics committees (e.g. nation or university) or local committees (e.g. hospitals).

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2.4. Statistical analysis All analyses were performed with nurses as the unit of analysis. In a first step, we checked for collinearity between variables using Spearman correlation coefficients. With correlations ranging from 0.38 to 0.62 for the PES-NWI subscales and correlations below 0.45 in all other cases, collinearity was not considered to be present. Therefore, multilevel regression analyses were conducted for ‘intention to leave the profession due to job dissatisfaction’ as the dependent variable, using the Laplace method in SAS version 9.2. Fourteen variables were included as fixed factors. These factors included all five subscales of the PESNWI, Patient to nurse staffing ratio on unit level, burnout, quality of care, safety of care, hospital size, age, gender, working full-time or part-time, and educational level. Country and hospital-unit were included as random factors. Gender, working full-time/part-time, educational level, quality of care and safety of care were treated as binary variables. The PES-NWI subscales were included as ratio variables, using the 25th and 75th percentile scores as reference points for calculating odds ratios from the model. With age, reference points for calculating odds ratios for this ratio variable were the mean age and age +10. For the burnout scale the score of 17 (low level) was used as a reference point and compared with a score of 27 (high level). In a secondary analysis, we repeated the procedure while using PES-NWI total scores instead of scores for the PES-NWI subscales. 3. Results 3.1. Sample A total of 23,159 nurses participated in this study. The overall response rate was 64%, and varied from 39% in the England to 97% in Poland. An overview of the numbers of participating nurses, nursing units and hospitals is given in Table 1. 3.2. Nurses’ intention to leave the profession Overall, 9% of the nurses intended to leave their profession due to job dissatisfaction (Table 2). For most countries, the proportion of nurses intending to leave their profession ranged from 9% to 11%. The proportion of nurses Table 1 Participating hospitals, nurses and units in 10 European countries. Nurses

Units

Belgium Finland Germany Ireland Netherlands Norway Poland Spain

67 32 49 30 28 35 30 33

3186 1131 1508 1406 2217 3752 2605 2804

272 126 199 112 131 238 119 281

72 46 47 56 69 57 97 84

Switzerland UK All countries

35 46 385

1632 2918 23,159

134 413 2025

72 39 64

Country

Hospitals

Response rate %

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Table 2 Intention to leave the hospital and the profession in 10 European countries. Country (number of nurses)

Nurses intending to leave the hospital workplace as % of all nurses

Belgium (n = 3186) Finland (n = 1131) Germany (n = 1508) Ireland (n = 1406) Netherlands (n = 2217) Norway (n = 3752) Poland (n = 2605) Spain (n = 2804) Switzerland (n = 1632) UK (n = 2918) Ten country mean (n = 23,159)

30

9

49 36 44 19 25 44 27 28 44 33

10 17 11 5 9 9 5 6 10 9

Nurses intending to leave the profession as % of all nurses

who intended to leave the profession was considerably lower in the Netherlands (5%), Spain (5%) and Switzerland (6%), and distinctly higher in Germany (17%). 3.3. Characteristics of nurses and their work environment Nurses’ mean age was 37.5 years and 93% of all nurses were female. More than half of the nurses (52%) had been educated on a bachelor level. This varied from 100% in Norway and Spain to 0% in Germany. In the ten country analysis, 23% of all nurses perceived the quality of care as being fair or poor. This proportion varied from 35% in the Netherlands to 11% in Ireland. Patient safety was perceived as failing or poor by 7% of all nurses, with percentages varying from 4% to 8% across countries. High levels of burnout were observed in more than a quarter of all nurses (28%), varying from 42% in the England to 10% in the Netherlands. Patient to nurse staffing ratios ranged from 12.3 in Spain to 5.2 in Norway, with a mean of 8.9 across the countries. Potential correlates of nurses’ intention to leave their profession are presented in Tables 3 and 4. The mean scores on the five subscales of the PES-NWI (Table 4) varied between 2.19 for the Perceived Staffing Adequacy dimension and 2.78 on the Nurse Foundations for Quality of Care dimension. The dimension Participation in Hospital Affairs scored 2.33 on average, while Leadership and Nurse Physician relationships had mean scores of 2.72 and 2.70 respectively. Switzerland had the highest scores on 4 out of 5 dimensions of the PES-NWI (for Participation in Hospital Affairs this was shared with Germany), while Poland scored lowest on 3 out of 5 PES-NWI dimensions. 3.4. Factors associated with intention to leave the nursing profession Factors associated with intention to leave the nursing profession are depicted in Table 5, presenting the results from an analysis for the ten countries taken together, as well as results from the analyses per country.

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Table 3 Descriptives for potential correlates of intention to leave nursing in 10 European countries. Country

Age mean (sd)

Gender % females

Bachelor degree %

Poor/fair quality %

Failing/poor safety%

Burnout scores mean (sd)

High burnout %

Staffing ratio patient/nurse

Hospital size (median beds)

Belgium Finland Germany Ireland Netherlands Norway Poland Spain Switzerland UK Total

37.8 41.7 38.8 34.6 37.0 35.4 40.6 38.2 35.2 39.7 37.5

90 97 89 94 92 94 100 90 92 92 93

56 53 0 60 32 100 22 100 10 28 52

28 13 35 11 35 13 27 32 20 19 23

6 7 6 8 6 5 18 6 4 7 7

19.0 18.6 21.1 24.5 14.2 19.7 24.4 21.0 16.3 24.6 20.4

25 22 30 41 10 24 40 29 15 42 28

10.4 7.8 12.8 6.8 6.9 5.2 10.5 12.3 7.8 8.6 8.9

335 382 447 332 420 356 655 598 280 486 429

(10.7) (10.4) (10.9) (8.7) (11.4) (10.6) (7.7) (9.8) (10.0) (10.1) (10.3)

(11.1) (9.9) (10.3) (11.5) (8.8) (9.8) (11.6) (11.4) (9.2) (11.5) (11.1)

Table 4 Scoresa on the five dimensions of the Practice Environment Scale (PES-NWI) in 10 European countries. Country

Staffing Mean (sd)

Nurse-physician relationship Mean (sd)

Leadership Mean (sd)

Nurse foundation for quality of care Mean (sd)

Participation in hospital affairs Mean (sd)

Belgium Finland Germany Ireland Netherlands Norway Poland Spain Switzerland UK All countries

2.13 (0.55) 2.27 (0.61) 2.02 (0.61) 2.04 (0.69) 2.40 (0.50) 2.45 (0.60) 1.86c (0.67) 2.09 (0.66) 2.51b (0.61) 2.13 (0.69) 2.19 (0.66)

2.58 (0.51) 2.91 (0.58) 2.65 (0.65) 2.66 (0.59) 2.79 (0.38) 3.01b (0.48) 2.26c (0.70) 2.42 (0.62) 2.92 (0.58) 2.89 (0.54) 2.70 (0.61)

2.61 (0.58) 2.68 (0.68) 2.58 (0.66) 2.70 (0.69) 2.80 (0.46) 2.90 (0.56) 2.50c (0.77) 2.61 (0.72) 3.07b (0.68) 2.77 (0.68) 2.72 (0.66)

2.77 (0.37) 2.73 (0.45) 2.91 (0.49) 2.88 (0.51) 2.77 (0.31) 2.60c (0.46) 2.72 (0.60) 2.60c (0.52) 3.15b (0.45) 2.97 (0.49) 2.78 (0.50)

2.30 (0.45) 2.23 (0.50) 2.65b (0.53) 2.33 (0.62) 2.40 (0.37) 2.31 (0.51) 2.25 (0.66) 2.00c (0.54) 2.65b (0.50) 2.45 (0.59) 1.33 (0.56)

a b c

Range 1–4, A higher score indicates a more positive perception of the dimension. Highest score. Lowest score.

The odds of Intention to leave the profession (OR 2.02; 95%CI 1.91–2.14) are twice as high in nurses with a high score on burnout in the ten countries analysis. The significance of this factor is mirrored by the results per country; burnout is a significant correlate of intention to leave in all ten countries. Odds ratios range from 1.56 (95%CI: 1.21–2.02) in Finland to 2.89 (95%CI: 2.18–3.82) in Switzerland, indicating that the odds of intention to leave the profession are one and a half to three times as high in nurses with a high score on burnout. Three out of five PES-NWI dimensions are significantly associated with intention to leave nursing at a cross national level. A more positive perception of Nurse participation in hospital affairs is associated with lower odds on intention to leave the profession in the ten country analysis (OR 0.68; 95%CI 0.61–0.76). Similar correlations were observed for seven out of ten countries: Belgium, Germany, the Netherlands, Poland, Norway, Switzerland and England. Also, in case of favourable Nurse–Physician Relationships, the ten country analysis indicated intention to leave the profession was less likely (OR 0.86; 95%CI 0.79–0.93). The same association was observed in Ireland, the Netherlands and Norway. Nurses who valued Leadership on their ward more positively have a lower intention to leave the profession in the ten country analysis (OR 0.78;

95%CI 0.70–0.86) as well as in five out of ten countries; Belgium, Finland, Germany, the Netherlands and England. Other significant associations with intention to leave were found for working full-time, age, and gender. At the ten country level (OR 0.76; 95%CI 0.66–0.86) and in Belgium, Finland, Norway and the England, nurses who work fulltime are less likely to consider a future outside nursing. Older nurses on the other hand are more likely to consider leaving their profession; this effect is found at the ten country level (OR 1.13; 95%CI 1.07–1.20) as well as in Germany, Spain and the England. Females are less likely to consider leaving the profession at the ten country level (OR 0.67; 95%CI 0.55–0.80), as well as in Belgium and Norway. Our secondary analysis indicated that PES-NWI as a single measure is significantly associated with intention to leave the profession for the ten countries together, as well as in all separate countries except for Switzerland. Odds ratios vary from 0.40 to 0.72. A positive perception of work environment is associated with approximately 30% less intention to leave the profession for the ten country analysis (OR = 0.57; CI: 0.53–0.63). Finally, several factors correlated with intention to leave in single countries only, or were not associated with intention to leave the profession in any of the countries. Patient to nurse staffing ratio, and perceived care quality did

M.M. Heinen et al. / International Journal of Nursing Studies 50 (2013) 174–184

not correlate with intention to leave the profession at the ten country level, nor in any of the individual countries. Nurse Perceived Staffing Adequacy (PES-NWI) correlated significantly with intention to leave in Germany only, and Nurse Foundations for Quality of Care (PES NWI) was positively related to intention to leave the profession in Swiss nurses alone. Perceived patient safety was significantly associated with intention to leave the profession in Belgium only, while hospital size was a significant factor only in Spain and educational level was a significant factor in two countries, i.e. Switzerland and Ireland, where nurses with higher training levels were less likely to consider leaving the profession. 4. Discussion This study investigated factors associated with intention to leave the profession due to job dissatisfaction in hospital-based nurses in ten European countries. Data from 23,159 nurses from 385 hospitals in ten European countries were used for this purpose. 4.1. Discussion of findings An intention to leave nursing was reported by 9% of all nurses, but this varied from 5 to 17% across the ten European countries. Flinkman et al. (2010) reported estimates of 4–54% in studies on nurses’ intention to leave the profession. Our findings from ten countries are towards the lower end of this range and less variable, probably in relation to uniform questioning and survey procedures across countries. The intention to leave percentage for Germany (17%) was notably higher than for all other countries (with 11% for Ireland as the second highest percentage). However, this is likely a valid estimate of German nurses’ intention to leave the profession as it closely matches an estimated 18% previously reported by Hasselhorn et al. (2003), who also reported similar findings for Poland (10% vs. 9% in our study). Burnout was significantly associated with intention to leave the profession at a European level and in all countries. These findings for Burnout reflect those reported in several studies, which also pointed at a clear relationship between intention to leave the profession and burnout of nurses (Collinson, 2000; Hasselhorn, 2005; Jourdain & Chenevert, 2010; Laine et al., 2005). Several previous studies pointed at the relevance of gender, age and educational levels (Flinkman et al., 2010). The relevance of age and gender was supported by results of the ten RN4CAST countries taken together. However, these results were not consistent and both age and gender seemed relevant in a minority of the countries only, where it should be noted that some of the countries showed little or no variation in gender. Results for gender were in line with earlier findings, indicating that males are more likely to consider leaving nursing (Barron and West, 2005; Hasselhorn et al., 2005). However, our study indicated older nurses were more likely to leave the profession while other authors reported that younger nurses were more likely to consider a professional future outside nursing

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(Barron and West, 2005; Hasselhorn et al., 2005; Kuokkanen et al., 2003). The relevance of educational level for intention to leave as indicated in previous studies (Barron and West, 2005; Hasselhorn et al., 2005; Laine et al., 2005) was largely unsupported by the RN4CAST data. Moreover, results from Ireland and Switzerland showed that educational level was a significant factor in the model contradicting previous reports on how nurses with higher training levels are more likely to consider leaving the profession (Vernooij-Dasssen et al., 2009). Again, it should be noted that the relevance of educational levels could not be tested for all countries, as three of the countries had no or very little variation in training levels. In addition, our assessment of educational level (bachelors’ level or not) might have lacked detail and the content and level of bachelor study programmes might still vary across countries. In the ten country analysis and in four of the countries, we found that nurses who work full-time are less likely to consider leaving nursing. These results seem to be in line with indications of how nurses with work–family conflicts and nurses whose income is not crucial to their family are more likely to consider leaving the profession (Hasselhorn et al., 2005; Lynn and Redman, 2005; Simon and Hasselhorn, 2004; Zeytinoglu et al., 2006). Results for PES-NWI subscales indicated especially how satisfactory nurse–physician relationships, leadership and participation in hospital affairs correlated negatively with intention to leave. These findings support earlier studies of how work environment aspects could be relevant to intentions of leaving nursing (Eley et al., 2007; EstrynBehar et al., 2010; Flinkman et al., 2010). The only counterintuitive finding here was a positive correlation between more favourable views on having a nursing foundation for quality of care (e.g. in relation to staff development and quality management) and intention to leave the profession due to job satisfaction in Swiss hospital nurses. An explanation for this might be that nurses working in an environment with a stronger focus on quality in nursing care become more easily frustrated by gaps in quality of care, and are therefore more often inclined to leave the profession. The inverse result for this subscale in Switzerland might explain the non-significant association between work environment as a whole (PES-NWI) and intention to leave the profession for this country. Though workload and perceived care quality are potential indicators of intention to leave a current employer (Aiken et al., 2012; Hayes et al., 2006), we could not confirm this for intention to leave the profession. Data from 10 out of 12 countries from the RN4CAST study did not point at perceived staffing adequacy, nurse–patient staffing ratio and perceived care safety and quality as important factors in relation to intention to leave nursing. Both the subjective and more objective nurse staffing variable did not correlate with intention to leave in this study. The correlation between the two nurse staffing variables was not high. As these variables were still moderately correlated however, we explored whether this could be due to including both variables in the analyses. When successively leaving out one of the two variables however, the remaining staffing variable remained statistically insignificant in the analysis.

180

Table 5 Correlates of intention to leave nursing from the multilevel analyses: odds ratio [95%CI].

TOTAL 10

BE

FI

GE

IRE

NL

NO

PO

SP

CH

Eng

countries Perceived staffing adequacy

0.95

1.05

1.27

0.66*

0.88

0.93

1.16

0.99

0.67

1.17

0.93

[0.84-1.06]

[0.81-1.36]

[0.91-1.77]

[0.47-0.92]

[0.60-1.29]

[0.60-1.44]

[0.87-1.54]

[0.72-1.37]

[0.44-1.03]

[0.75-1.84]

0.65-1.32

(pes-nwi) Nurse-physician relaonship

0.86*

0.95

0.92

0.79

0.76*

0.68*

0.87*

0.80

0.91

0.88

0.92

[0.79-0.93]

[0.76-1.20]

[0.68-1.24]

[0.62-1.01]

[0.58-0.98]

[0.53-0.89]

[0.77-0.99]

[0.58-1.10]

[0.65-1.28]

[0.72-1.08]

0.79-1.08

Leadership

0.78*

0.67*

0.56*

0.74*

0.87

0.66*

0.88

1.14

0.78

0.82

0.70*

(pes-nwi)

[0.70-0.86]

[0.54-0.85]

[0.37-0.86]

[0.58-0.94]

[0.61-1.25]

[0.49-0.88]

[0.71-1.08]

[0.86-1.52]

[0.51-1.18]

[0.59-1.14]

0.50-0.97

Nurse foundaon

1.07

1.06

1.01

1.06

0.75

1.39

1.04

1.11

0.96

1.65*

1.27

for quality of care

[0.97-1.19]

[0.86-1.31]

[0.68-1.51]

[0.78-1.43]

[0.53-1.06]

[0.92-2.09]

[0.82-1.30]

[0.84-1.48]

[0.65-1.43]

[1.10-2.48]

0.91-1.77

0.68*

0.55*

0.79

0.65*

0.84

0.62*

0.67*

0.64*

0.77

0.59*

0.60*

[0.61-0.76]

[0.42-0.72]

[0.53-1.18]

[0.48-0.89]

[0.55-1.27]

[0.42-0.93]

[0.53-0.86]

[0.44-0.95]

[0.49-1.19]

[0.38-0.93]

0.42-0.87

Nurse-paent

0.99

1.02

1.15

0.92

0.93

1.13

0.99

0.81

1.06

1.18

1.03

staffing rao

[0.96-1.01]

[0.83-1.27]

[0.87-1.51]

[0.76-1.20]

[0.69-1.25]

[0.76-1.69]

[0.83-1.17]

[0.66-1.00]

[0.80-1.43]

[0.83-1.66]

0.81-1.30

1.13*

0.88

1.02

1.20*

0.92

1.06

1.09

1.18

1.39*

0.96

1.66*

[1.07-1.20]

[0.75-1.03]

[0.79-1.31]

[1.03-1.40]

[0.71-1.20]

[0.84-1.33]

[0.96-1.24]

[0.93-1.50]

[1.13-1.71]

[0.73-1.26]

1.38-1.99

(pes-nwi) Parcipaon in hospital affairs (pes-nwi)

Age: older

Gender: female

0.67*

0.60*

1.09

0.70

0.61

0.35*

1.32

0.63

0.70

[0.55-0.80]

[0.38-0.95]

[0.65-1.81]

[0.33-1.49]

[0.29-1.28]

[0.23-0.55]

[0.64-2.72]

[0.31-1.30]

0.40-1.23

0.76*

0.67*

0.34*

0.83

0.68

1.01

0.70*

0.54

2.21

0.76

0.57*

[0.66-0.86]

[0.49-0.93]

[0.15-0.75]

[0.59-1.16]

[0.41-1.12]

[0.60-1.69]

[0.54-0.92]

[0.21-1.42]

[0.76-6.45]

[0.45-1.30]

0.39-0.83

0.88

0.95

1.00

0.55*

1.15

0.30*

1.36

bachelor

[0.76-1.03]

[0.70-1.29

[0.60-1.67]

[0.35-0.85]

[0.69-1.90]

[0.10-0.90]

0.93-1.20

Burnout

2.02*

2.00*

1.56*

1.72*

1.75*

1.73*

2.50*

1.99*

1.93*

2.89*

2.08*

[1.91-2.14]

[1.73-2.32]

[1.21-2.02]

[1.44-2.05]

[1.44-2.13]

[1.35-2.23]

[2.15-2.90]

[1.70-2.32]

[1.60-2.34]

[2.18-3.82]

1.74-2.49

Hours/week: fullme Training level:

0.83 [0.54-1.29]

M.M. Heinen et al. / International Journal of Nursing Studies 50 (2013) 174–184

(pes-nwi)

Perceived care quality: poor/fair-

1.09

0.97

0.56

1.06

1.58

1.33

1.19

1.04

1.14]

1.64

0.86

[0.95-1.25]

[0.69-1.37]

[0.27-1.13]

[0.73-1.54]

[0.90-2.76]

[0.79-2.26]

[0.83-1.71]

[0.70-1.55]

[0.72-1.80]

[0.91-2.96]

0.54-1.36

good/excellent Perceived safety:

1.15

1.56*

1.27

0.98

0.67

1.36

0.90

1.45

0.88

0.92

A. Acceptable vs

[1.01-1.32]

[1.07-2.29]

[0.74-2.18]

[0.66-1.44]

[0.42-1.08]

[0.98-1.90]

[0.59-1.37]

[0.84-2.49]

[0.50-1.54]

0.62-1.38

good; B. Good vs unsafe

*Medium vs large

e

0.71

0.61

0.76

0.93

1.00

1.09

0.90

2.04

0.74

[0.45-1.12]

[0.28-1.32]

[0.44-1.31]

[0.50-1.74]

[0.63-1.58]

[0.70-1.68]

[0.49-1.63]

[0.77-5.45]

0.41-1.33

0.87

0.45*

0.48

0.78

1.39

0.74

1.22

0.62

2.32

0.81

[0.70-1.08]

[0.26-0.80]

[0.19-1.20]

[0.41-1.50]

[0.72-2.68]

[0.42-1.29]

[0.69-2.15]

[0.29-1.35]

[0.76-7.11]

0.41-1.57

1.05

1.10

0.90

1.06

1.14

0.87

1.16

0.92

1.56

0.77

1.10

[0.91-1.23]

[0.75-1.60]

[0.53-1.53]

[0.69-1.62]

[0.74-1.56]

[0.41-1.86]

[0.82-1.63]

[0.60-1.41]

[0.78-3.14]

[0.44-1.37]

0.65-1.85

1.01

0.69

1.05

0.93

1.54

1.04

0.91

0.69

0.93

1.53

[0.87-1.19]

[0.45-1.06]

[0.58-1.92]

[0.61-1.42]

[0.88-2.71]

[0.41-2.64]

[0.66-1.26]

[0.37-1.29]

[0.50-1.72]

0.90-2.61

0.96

0.63

1.17

0.88

1.35

1.20

0.79

0.44*

1.20

1.39

[0.84-1.11]

[0.42-0.95]

[0.66-2.08]

[0.60-1.29]

[0.77-2.36]

[0.59-2.43]

[0.54-1.16]

[0.26-0.75]

[0.61-2.37]

0.93-2.09

Safety: 1 is acceptable vs. good; 2e is acceptable vs. not safe; 3e is good vs. not safe. HSIZE; 1 = less than 300 beds; 2 = 300–600 beds; 3 = more than 600 beds. Small vs. medium; small vs. large; medium vs. large. Grey – insufficient variation to include this factor in the analysis. * Significant correlates at the 0.05 level.

M.M. Heinen et al. / International Journal of Nursing Studies 50 (2013) 174–184

Hosptal size:

1.00 [0.84-1.20]

181

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This suggests that issues with staffing adequacy, nurse patient ratio, perceived quality and safety of patient care, are not strong enough to push nurses out of the profession altogether. Perhaps these are contextual factors that may be corrected in a new work environment. However, it is possible that with repeated exposure across work settings (i.e., different employers), or during one’s professional career, there is an attributional shift such that the problem of for example a high patient to nurse ratio is viewed as an artifact of the profession rather than the specific situational context within a few organisations. Support for this generalisation requires longitudinal evidence as well as further investigation. 4.2. Strengths and limitations Although many studies addressed nurses’ intentions about leaving their job or organisation; fewer studies focused on intention to leave their profession. With results from ten European countries, uniform data collection methodology across countries and by using several wellestablished survey tools, the RN4CAST project delivered robust results. Therefore, this study contributes significantly to knowledge development in the area of nurses’ intention to leave their profession, where a lack of sound and consistent measurement instruments and a lack of rigorous sampling hindered our comprehension of the phenomenon and potential determinants (Flinkman et al., 2010). Some limitations have to be acknowledged however. While RN4CAST was a European project, ten countries do not constitute the whole of Europe. Also, one could debate if European countries are sufficiently comparable to perform an analysis at a multinational level. Differing nurses’ educational programmes, as well as the organisation of health care, and hospitals in particular, could limit comparability of findings across countries. All data in our analysis stemmed from nurse surveys. This implies we have no other estimates to control for factors such as work environment. Furthermore, some measures like perception of quality and safety of care were single item measures, which are in general regarded as less valid than multi-item measures (Sermeus et al., 2011). Nevertheless, we argue that in addition to more objective factors, nurse perceived factors should be the focus of attention in attempts at explaining why nurses consider leaving their profession. Our design and analyses do not allow for conclusions on causality. Though statistically advanced, our analyses were essentially simple. After ruling out collinearity among variables, we inserted all factors possibly associated with intention to leave the profession in a model for all countries and models for individual countries. These analyses merely point at significant correlates of intention to leave the profession. They do not allow for confirmation or building of explanatory models. However, given the limited insight into what causes intention to leave the profession (Flinkman et al., 2010), using alternative analytical approaches such as path analyses on our data could not depart from sufficiently supported hypotheses. So as not to make ill-substantiated suggestions on mechanisms and causality, we therefore performed our rather straightforward analyses on these cross-sectional data. Our results are based on models

incorporating several factors at a time, and it could be argued that the effects of relatively objective variables were levelled out by factors which are conceptually closer to intention to leave the profession, such as nurses’ subjective feelings of burnout. Such a concern is not substantiated by our findings however; the more objective factors nurse– patient staffing ratio and hospital size, which were not significant in the overall model, and showed very low bivariate correlations with intention to leave the profession (Spearman correlation of 0.03 and 0.01 respectively). Finally, not all factors could be included in the analyses for each of the countries. With gender this is probably not problematic; a lack of male nurses points at recruitment rather than retention issues. A lack of variation in educational levels with three countries raises more questions. It is likely that our rather crude assessment of educational level (bachelor or diploma level) did not capture relevant variation and potential relationships with intention to leave the profession. 4.3. Conclusion Burnout is consistently associated with nurses’ intention to leave their profession within and across European countries. Nurse–patient staffing ratio, hospital size and nurses’ assessments of staffing adequacy, care quality and educational level are not related to intention to leave the nursing profession. The relevance of other factors is less clear and varies across the ten countries. Unsatisfactory nurse–physician relationships, leadership, a lack of participation in hospital affairs, older age, male gender and working part-time seem relevant at an international level, but highly variable results for individual countries illustrate how a convincingly valid European model for nurses’ intention to leave their profession cannot be presented. 4.4. Future research Our study demonstrated how some factors seem consistently important or not important at both national and cross-national levels, whereas the relevance of other factors associated with intention to leave the profession may be country specific. This implies how national studies on intention to leave the profession remain important for the development of adequate retention policies. Most studies on intention to leave the profession report on cross-sectional data. Performing robust longitudinal studies, for example to explore nurses’ careers in view of their intention to leave their profession and factors supporting job retention in nursing is the main future challenge in this area, as this will allow for less speculative and more grounded conclusions on causal pathways and thus valid action plans. 4.5. Practice implications A number of reports suggest that a significant increase in demand for nursing services is expected in the forthcoming years. It is of critical importance for managerial staff and leadership to understand and act on factors which influence nurses’ decision to leave or remain in their profession.

M.M. Heinen et al. / International Journal of Nursing Studies 50 (2013) 174–184

Burnout appears to be a key factor in this respect. Studies on burnout in nurses point at various possible solutions such as decreasing job demands, minimising inconvenient shifts, increasing job resources, task restructuring, or other measures to create productive and healthy work environments (Flinkman et al., 2008; Jourdain and Chenevert, 2010). Kramer and Schmalenberg (2004, 2008) identified working with competent peers, collaborative nurse–physician relationships, clinical autonomy, nurse manager support, control over nursing practice, perceived adequacy of staffing, support for education and a patientdirected culture as key elements of satisfactory work environment in hospitals. While the relevance of perceived staffing adequacy is not supported by our results on intention to leave the profession, this and other factors from these ‘essentials of magnetism’ for USA-hospitals can be relevant in preventing burnout; this has already been partly substantiated by European studies. Whereas employers can have a crucial role in creating healthy work environments, it could be questioned whether young nurses are sufficiently empowered to cope with work-related stressors and to create satisfactory working conditions themselves. Along with educators and policy makers, employers and educators have to play an important role in this respect. Conflict of interest No conflicts of interest are reported. Funding This study was funded by the European Union’s Seventh Framework Programme (FP7/2007–2013) under grant Agreement No. 223468. Ethical approval Depending on national legislation, the study protocol was approved by either central ethical committees (e.g. nation or university) or local ethical committees (e.g. hospitals). The consortium has developed strict criteria (included in the project proposal and additional internal documents) regarding the sampling of nurses and patients, the storage, flows and access of the data to safeguard the security, privacy and confidentiality. Appendix A The RN4CAST Consortium consists of Walter Sermeus, Koen Van den Heede, Luk Bruyneel, Emmanuel Lesaffre, Luwis Diya (Belgium, Catholic University Leuven); Linda Aiken, Herbert Smith, Timothy Cheney, Douglas Sloane (USA, University of Pennsylvania); Juha Kinnunen, Anneli Ensio, Virpi Jylha¨ (Finland, University of Eastern Finland); Reinhard Busse, Britta Zander (Germany, Technical University Berlin); John Mantas, Dimitirios Zikos (Greece, University of Athens); Anne Scott, Anne Matthews, Anthony Staines (Ireland, Dublin City University); Ingeborg Strømseng Sjetne (Norway, Norwegian Knowledge Center for the Health Services); Thomas Brzostek, Maria Ko´zka, Piotr Brzyski, Lucyna

183

Przewoz´niak, Anna Ksykiewicz-Dorota (Poland, Jagiellonian University Medical College); Teresa Moreno-Casbas, Carmen Fuentelsaz-Gallego, Esther Gonzalez-Marı´a, 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, Rene´ Schwendimann (Switzerland, Basel University); Maud Heinen, Lisette Schoonhoven, Theo van Achterberg (The Netherlands, Radboud University Nijmegen Medical Centre); Peter Griffiths (England, University of Southampton); Jane Ball, Simon Jones, Brian McIntosh, Anne Marie Rafferty (England, King’s College London).

References Aiken, L.H., Patrician, P.A., 2000. Measuring organizational traits of hospitals: the Revised Nursing Work Index. Nursing Research 49 (3), 146–153. Aiken, L.H., Clarke, S.P., Sloane, D.M., 2002. Hospital staffing, organization, and quality of care: cross-national findings. International Journal for Quality in Health Care 14 (1), 5–13. Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., Kutney-Lee, A., 2012. 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 344, e1717. Barron, D., West, E., 2005. Leaving nursing: an event-history analysis of nurses’ careers. Journal of Health Services Research and Policy 10 (3), 150–157, http://dx.doi.org/10.1258/1355819054338924. Collinson, G., 2000. Encouraging the growth of the nurse entrepreneur. Professional Nurse 15 (6), 365–367. Coombs, C., Arnold, J., Loan-Clarke, J., Wilkinson, A., Park, J., Preston, D., 2003. Perceptions of nursing in the NHS. Nursing Standard 18 (5), 33–38. de Veer, A., den Ouden, D.J., Francke, A., 2004. Experiences of foreign European nurses in The Netherlands. Health Policy 68 (1), 55–61, http://dx.doi.org/10.1016/j.healthpol.2003.08.006 S0168851003001714 [pii]. Eley, R., Buikstra, E., Plank, A., Hegney, D., Parker, V., 2007. Tenure, mobility and retention of nurses in Queensland, Australia: 2001 and 2004. Journal of Nursing Management 15 (3), 285–293, http:// dx.doi.org/10.1111/j.1365-2834.2007.00652.x JNM652 [pii]. Estryn-Behar, M., van der Heijden, B.I., Fry, C., Hasselhorn, H.M., 2010. Longitudinal analysis of personal and work-related factors associated with turnover among nurses. Nursing Research 59 (3), 166–177. Flinkman, M., Laine, M., Leino-Kilpi, H., Hasselhorn, H.M., Salantera, S., 2008. Explaining young registered Finnish nurses’ intention to leave the profession: a questionnaire survey. International Journal of Nursing Studies 45 (5), 727–739, http://dx.doi.org/10.1016/j.ijnurstu.2006.12.006 S0020-7489(06)00347-6 [pii]. Flinkman, M., Leino-Kilpi, H., Salantera, S., 2010. Nurses’ intention to leave the profession: integrative review. Journal of Advanced Nursing 66 (7), 1422–1434, http://dx.doi.org/10.1111/j.1365-2648.2010.05322.x JAN5322 [pii]. Hasselhorn, H.M., 2005. The health of nursing personnel in the hospital. Krankenpflege Journal 43 (7–10), 173–175. Hasselhorn, H.M., Tackenberg, P., Muller, B.H., 2003. Premature departure from nursing in Germany as a growing problem for the health care system – a review. Gesundheitswesen 65 (1), 40–46, http:// dx.doi.org/10.1055/s-2003-36918. Hasselhorn, H.M., Muller, B.H., Tackenberg, P., Simon, M., Kummerling, A., Buscher, A., 2005. Ensuring the future—shaping the future. Pflege Aktuell 59, 99–102. Hayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., Stone, P.W., 2006. Nurse turnover: a literature review. International Journal of Nursing Studies 43 (2), 237–263. Jourdain, G., Chenevert, D., 2010. Job demands–resources, burnout and intention to leave the nursing profession: a questionnaire survey. International Journal of Nursing Studies 47 (6), 709–722, http:// dx.doi.org/10.1016/j.ijnurstu.2009.11.007 S0020-7489(09)00363-0 [pii]. Kramer, M., Schmalenberg, C., 2004. Development and evaluation of essentials of magnetism tool. Journal of Nursing Administration 34 (7–8), 365–378 00005110-200407000-00010 [pii]. Kramer, M., Schmalenberg, C., 2008. Confirmation of a healthy work environment. Critical Care Nurse 28 (2), 56–63 quiz 64. 28/2/56 [pii]

184

M.M. Heinen et al. / International Journal of Nursing Studies 50 (2013) 174–184

Kuokkanen, L., Leino-Kilpi, H., Katajisto, J., 2003. Nurse empowerment, job-related satisfaction, and organizational commitment. Journal of Nursing Care Quality 18 (3), 184–192. Laine, J., Noro, A., Finne-Soveri, H., Hakkinen, U., 2005. Patient- and wardlevel determinants of nursing time in nursing facilities. Journal of Health Services Research and Policy 10 (4), 226–231, http:// dx.doi.org/10.1258/135581905774414178. Lesniowska, J., 2008. Poland’s nursing brain drain to the West. Health Affairs (Millwood) 27 (2), 593, http://dx.doi.org/10.1377/ hlthaff.27.2.593 27/2/593 [pii]. Lynn, M.R., Redman, R.W., 2005. Faces of the nursing shortage: influences on staff nurses’ intentions to leave their positions or nursing. Journal of Nursing Administration 35 (5), 264–270 00005110-20050500000010 [pii]. Maslach, C.J.S.L.M (Ed.), 1996. Maslach Burnout Inventory: Manual. 3rd ed. Consulting Psychologist Press, Palo Alto, CA. Murrells, T., Robinson, S., Griffiths, P., 2008. Is satisfaction a direct predictor of nursing turnover? Modelling the relationship between satisfaction, expressed intention and behaviour in a longitudinal cohort study. Human Resources for Health 6, 22, http://dx.doi.org/ 10.1186/1478-4491-6-22 1478-4491-6-22 [pii]. Sermeus, W., Aiken, L.H., Van den Heede, K., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Zikos, D., 2011. Nurse forecasting in Europe (RN4CAST): rationale, design and methodology. BMC Nursing 10, 6, http://dx.doi.org/10.1186/1472-6955-10-6 1472-6955-10-6 [pii]. Simoens, S.V.M.H.J., 2005. Tackling Nurse Shortages in OECD Countries. OECD Health Working Papers. Simon, J.P.K.A., Hasselhorn, H., 2004. Work–home conflict in the European nursing profession. International Journal of Occupational & Environmental Health 10 (4), 384–391.

Squires, A., Aiken, L.H., van den Heede, K., Sermeus, W., Bruyneel, L., Lindqvist, R., Zikos, D., 2012. A systematic survey instrument translation process for multi-country, comparative health workforce studies. International Journal of Nursing Studies, http://dx.doi.org/ 10.1016/j.ijnurstu.2012.02.015 S0020-7489(12)00060-0 [pii]. van Bogaert, P., Clarke, S., Vermeyen, K., Meulemans, H., Van de Heyning, P., 2009. Practice environments and their associations with nurse-reported outcomes in Belgian hospitals: development and preliminary validation of a Dutch adaptation of the Revised Nursing Work Index. International Journal of Nursing Studies 46 (1), 54–64. van der Heijden, B.I., Kummerling, A., van, D.K., van der, S.E., Estryn-Behar, M., Hasselhorn, H.M., 2010. The impact of social support upon intention to leave among female nurses in Europe: secondary analysis of data from the NEXT survey. International Journal of Nursing Studies 47 (4), 434–445. Vernooij-Dasssen, M.J., Faber, M.J., Olde Rikkert, M.G., Koopmans, R.T., van Achterberg, T., Braat, D.D., Wollersheim, H., 2009. Dementia care and labour market: the role of job satisfaction. Aging and Mental Health 13 (3), 383–390, http://dx.doi.org/10.1080/13607860902861043 911822245 [pii]. Warshawsky, N.E., Havens, D.S., 2011. Global use of the practice environment scale of the nursing work index. Nursing Research 60 (1), 17–31, http://dx.doi.org/10.1097/NNR.0b013e3181ffa79c. Zeytinoglu, I.U., Denton, M., Davies, S., Baumann, A., Blythe, J., Boos, L., 2006. Retaining nurses in their employing hospitals and in the profession: effects of job preference, unpaid overtime, importance of earnings and stress. Health Policy 79 (1), 57–72, http://dx.doi.org/ 10.1016/j.healthpol.2005.12.004 S0168-8510(05)00299-X [pii].