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Nurses on the move?
Findings from the Irish RN4CAST study
Matthews A, Scott PA, Kirwan M, Lehwaldt D, Staines ADublin City University
Outline
• Nurse migration• RN4CAST study• Nurse survey – data collection methods• Overall results• Comparison of results for nurses who trained/
were educated in Ireland or elsewhere– Focus on
• Perceptions of the work environment• Intention to leave current job due to dissatisfaction
Nurses “on the move”• A sustainable and motivated nursing workforce makes
a major contribution to each national health system; • Understanding nurse migration is central to workforce planning
efforts nationally and globally and to how we think about the nursing contribution to healthcare in Ireland and elsewhere, in the context of the WHO Global code of practice on the international recruitment of health personnel.
• Nurses tend to be “on the move” for various personal and professional reasons
• Ireland has relied heavily in the past decade on the active recruitment of migrant nurses to make up foreseeable shortfalls of nurses; – a “quick fix” Humphries et al (2009)
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•Funded under the European Framework 7 Programme•Running 1 January 2009 – 31 December 2011•Objectives:
• to refine current forecasting models for nursing with new elements, such as • (perceptions of) various aspects of the nursing work
environment and • the impact of nurse and organisational characteristics on
recruitment, retention and productivity of nurses and on patient outcomes
• To present mid-term and long-term workforce projections/ scenarios on a European and national level
RN4CAST project
RN4CAST-consortium
With Norway as additional partner, from mid 2009
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Project structure
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Nurse questionnaire Patient questionnaire
Hospital discharge data Hospital characteristics
Data collection methods in each country
N= 1,406 (= response rate 56%), 30 hospitals
N= 285, 10 hospitals
30 hospitals 30 hospitals
Ethical approval obtained from 18 Committees for 30 acute public hospitals in Ireland
Hospitals- shifting work environments
• 115 units in 30 hospitals • 10 large hospitals (>400 beds); 12 medium hospitals
(200-399 beds); 8 small hospitals (<200 beds)• Clinical areas: emergency (30), intensive care (28),
open heart surgery (4) and transplant surgery (4) • Many changes:
– reconfiguration of wards (19), substantial decrease in bed numbers (11), new facilities opened (11), new buildings opened (11), closure of major facilities (8), mergers with other hospitals (8), substantial increase in bed numbers (4)
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The nursing work environment: Practice Environment Sub-scale of the Nursing Work Index Staffing and resource adequacy, Nursing foundations of quality of care, Nurse
Participation in Hospital Affairs, Nurse manager ability, leadership and support for
nurses, Collegial nurse-physician relationships
Level of burnout (Maslach Burnout Inventory): Emotional Exhaustion,
Depersonalisation and Personal Accomplishment
Job satisfaction, intention to leave Quality and safety Nursing care “workload” Characteristics of nurses: Age, gender, migration, experience
Nurse questionnaire
Demographic profile- all respondents
• Gender: 93.7% female (n= 1,297), 6.3% male (n=87)• Age profile: 75% (n= 1,031) aged 20-39• 84% working full-time (n=1,149)• 45% medical wards, 48% surgical, remainder mixed• 50% (n=331) less than 5 years at hospital, 29.1%
(n=382) 5-10 years at hospital• 60% have a degree level education (level per hospital
ranges 25-84%)• 60% received their basic nursing training/education
in Ireland– We did not ask about nationality
Country of training & education level
Of the 40% who did not train in Ireland
Country n %
United Kingdom 274 54
India 111 22
Philippines 92 18
Other European countries
9 2
US, Australia, New Zealand
9 2
African countries 4 1
Others (including China)
4 1
Missing 33
Total 536 100
64
36
95
53
67
0
10
20
30
40
50
60
70
80
90
100
Ireland UK Phillipines India Other
Country of basic nurse education
% w
ith
deg
ree
Significant difference on degree level education in Ireland
vs all elsewhere: χ² 115.926, df 4, p = 0.000
Intention to leave by country of education
χ² = 23.581, df 4, p<0.001
Intention to leave
Total Education
(all results as valid %) N= 1406 EUn=1108
NonEUn=216
Would leave current job in next year if possible, due to dissatisfaction
44.3 45.7 35.6*
Stated very or fairly difficult to find another job
79.6 86.6 60*
Would definitely or probably recommend place of work to colleagues
67.7 66.9 79.2*
High emotional exhaustion level 41.41% 42.3 35.5
* Denotes statistical significant difference, p= 0.007, 0.000, 0.000 respectively
Predicting intention to leave?• Logistic regression was undertaken to predict intention
to leave– Predictive variables included:
• Nurse level: Place of nurse education/training (EU/nonEU) age group (under or over 30), education level (degree or not), level of burnout (emotional exhaustion level), satisfaction with nursing.
• Hospital level: size of the hospital and work environment rating (by nurse)
• Checked for multicollinearity amongst independent variables- absent
• Model supported (goodness of fit χ² = 278.396, df 6, p < 0.001 ; explained between 20.3% & 27.1% (pseudo R square) of intention to leave
• The only variables not contributing to the model were EU/non-EU nurse education (Wald 0.12, p= 0.912) and size of hospital (Wald 0.178, p 0.673)
Differences by country of education• Significant differences according to country of
education (ANOVAS) :– Intention to leave
• India and: Ireland, UK & Philippines: (order of increasing intention to leave: India, UK, Ireland, Philippines, Other)
– Burnout: • India and: Ireland & UK (order of increasing burnout level: India,
Ireland, UK)– Satisfaction with work environment & work environment
rating:• All show signif. Differences: UK, Ireland, Philippines, India (in order of
increasing satisfaction)– Nursing work environment rating
• Significant differences on most sub-scales between most groups: (UK, Ireland, Philippines, India)
Comparing countries
Country= country where basic nursing education received
Overall results, within RN4CAST
Key findings • Overall there are high levels of burnout and high levels
of intention to leave due to job dissatisfaction, although the difficulty in getting another acceptable job in nursing is acknowledged
• Nurses who received their basic nursing education in India are more satisfied with their work environment and less likely to leave their current job; – nurses educated in the Philippines more likely to have stated
intention to leave, differences between those educated in India and both UK and Ireland are statistically significant (higher)
• Having EU/non-EU nurse education does not contribute to predicting intention to leave due to dissatisfaction
Limitations
• Acute adult medical and surgical settings only• Response rate- response rate per hospital ranged from
38-78%, with an overall response rate of 56%– Response rates at ward level ranged from just 5- 100% (from
1 to 24 respondents)
• Some account taken of hospital variation, but unit/ward level variation also- multilevel analysis planned
• Unequal group sizes when comparing country, or EU/nonEU, where education was received
Conclusions • Some of these findings echo those of the RCSI Nurse
Migration Project research team – Highlight the need to retain current nursing staff, with
additional pressures now; qualitative studies help to interpret our findings
• The economic and healthcare context in Ireland has changed drastically in the past 2-3 years– Recruitment embargo 2009, public sector pay cuts and
income levies, Public Service Agreement 2010, ongoing reconfiguration of services
– Will continue to negatively affect the work environment, while also reducing mobility possibilities within Ireland
• The emphasis has shifted to self-sufficiency/ sustainability of healthcare workforces; in tension with issues of freedom of movement, the value of nurse migration?
