Nurses on the move? Findings from the Irish RN4CAST study Matthews A, Scott PA, Kirwan M, Lehwaldt D, Staines A Dublin 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)

4 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

6 Project structure

7 Nurse questionnaire Patient questionnaire Hospital discharge dataHospital characteristics Data collection methods in each country N= 1,406 (= response rate 56%), 30 hospitals N= 285, 10 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 ( 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)

9  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 % 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 Countryn% United Kingdom27454 India11122 Philippines9218 Other European countries 92 US, Australia, New Zealand 92 African countries41 Others (including China) 41 Missing33 Total Significant difference on degree level education in Ireland vs all elsewhere: χ² , df 4, p = 0.000

Intention to leave by country of education χ² = , df 4, p<0.001

Intention to leave TotalEducation (all results as valid %)N= 1406EU n=1108 NonEU n=216 Would leave current job in next year if possible, due to dissatisfaction * Stated very or fairly difficult to find another job * Would definitely or probably recommend place of work to colleagues * High emotional exhaustion level41.41% * Denotes statistical significant difference, p= 0.007, 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 = , df 6, p < ; 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 % (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?

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