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Paediatric attendances at the emergency department (ED) are often admitted to the hospital less than 24 h to allow time for more extended evaluation. Innovative organisational models could prevent these hospital admissions without compromising safety or quality of delivered care. Therefore, this systematic review identifies evidence on organisational models at the ED with the primary aim to reduce hospital admissions among paediatric patients. Following the PRISMA guidelines, three bibliographic databases (Ovid Medline, Embase, and Cochrane Library) were searched. Studies on organisational models in Western countries, published between January 2009 and January 2021, which applied a comparative design or review and studied at least hospital admission rates, were included. Analyses were mainly descriptive because of the high heterogeneity among included publications. The primary outcome is hospital admission rates. Secondary outcomes are ED length of stay (LOS), waiting time, and patient satisfaction. Sixteen publications described several innovative organisational models ranging from the creation of dedicated units for paediatric patients, innovative staffing models to bringing paediatric critical care physicians to patients at rural EDs. However, the effect on hospital admission rates and other outcomes are inconclusive, and some organisational models may improve certain outcomes in certain settings or vice versa. It appears that a paediatric consultation liaison team has the most consistent effect on hospital admission rates and LOS of paediatric patients presenting with mental problems at the ED. Implementing new innovative organisational models at the ED for paediatric patients could be worthwhile to decrease hospital admissions. However, the existing evidence is of rather weak quality. Future service developments should, therefore, be conducted in a way that allows objective evaluation.

Chronic hospital nurse understaffing is a pre-existing condition of the COVID-19 pandemic. With nurses on the frontline against the pandemic, safe nurse staffing in hospitals is high on the political agenda of the responsible ministers of Health. This paper presents a recent Belgian policy reform to improve nurse staffing levels. Although the reform was initiated before the pandemic, its roll-out took place from 2020 onwards. Through a substantial increase of the hospital budget, policy makers envisaged to improve patient-to-nurse ratios. Yet, this ambition was considerably toned down during the implementation. Due to a shortage of nurses in the labour market, hospital associations successfully lobbied to allocate part of the budget to hire non-nursing staff. Moreover, other healthcare settings claimed their share of the pie. Elements of international best-practice examples such as ward managers supernumerary to the team and increasing the transparency on staffing decisions were adopted. Other measures, such as mandated patient-to-nurse ratios, nurse staffing committees, or the monitoring or public reporting of ratios, were not retained. Additional measures were taken to safeguard that bedside staffing levels would improve, such as the requirement to demonstrate a net increase in staff to obtain additional budget, staffing plan's approval by local work councils and recommendation to base staff allocation on patient acuity measures. This policy process makes clear that the engagement of budgets is only a first step towards safe staffing levels, which needs to be embedded in a comprehensive policy plan. Future evaluation of bedside nurse staffing levels and nurse wellbeing is needed to conclude about the effectiveness of these measures and the intended and unintended effects they provoked.

Intensive care unit (ICU) nurses are at an increased risk of burnout and may have an intention-to-leave their jobs. The COVID-19 pandemic may increase this risk.The objective of this study was to describe the prevalence of burnout risk and intention-to-leave the job and nursing profession among ICU nurses and to analyse the relationships between these variables and the work environment after two years of the COVID-19 pandemic.A national cross-sectional survey of all nurses working in Belgian ICUs was conducted between December 2021 and January 2022 during the 4th and 5th waves of the COVID-19 pandemic in Belgium. The Practice Environment Scale of the Nursing Work Index (PES-NWI) was used to measure the work environment, intention-to-leave the hospital and/or the profession was assessed. The risk of burnout was assessed using the Maslach Burnout Inventory scale including emotional exhaustion, depersonalisation, and reduced personal accomplishment.Nurses in 78 out of 123 Belgian hospital sites with an ICU participated in the survey.2321 out of 4851 nurses (47.8%) completed the entire online survey.The median overall risk of burnout per hospital site (high risk in all three subdimensions) was 17.6% [P25: 10.0 - P75: 28.8] and the median proportion of nurses with a high risk in at least one subdimension of burnout in Belgian ICUs was 71.6% [56.7-82.7]. A median of 42.9% [32.1-57.1] of ICU nurses stated that they intended-to-leave the job and 23.8% [15.4-36.8] stated an intent-to-leave the profession. The median overall score of agreement with the presence of positive aspects in the work environment was 49.0% [44.8-55.8]. Overall, nurses working in the top 25% of best-performing hospital sites with regard to work environment had a statistically significant lower risk of burnout and intention-to-leave the job and profession compared to those in the lowest performing 25% of hospital sites. Patient-to-nurse ratio in the worst performing quartile was associated with a higher risk for emotional exhaustion (OR = 1.53, 95% CI:1.04-2.26) and depersonalisation (OR = 1.48, 95% CI:1.03-2.13) and intention-to-leave the job (OR = 1.46, 95% CI:1.03-2.05).In this study, a high prevalence of burnout risk and intention-to-leave the job and nursing profession was observed after two years of the COVID-19 pandemic. Nevertheless, there was substantial variation across hospital sites which was associated with the quality of the work environment."Burnoutintention to leave was high for Belgian ICU nurses after 2 years of COVID, but wellbeing was better with high quality work environments and more favourable patient to nurse ratios".

In April 2015, the Belgian Federal Minister for Social Affairs and Public Health launched an Action Plan to reform the hospital landscape. With the creation of "localregional clinical hospital networks" with their own governance structures, the plan follows the international trend towards hospital consolidation and collaboration. The major complicating factors in the Belgian context are (1) that policy instruments for the redesign of the hospital service delivery system are divided between the federal government and the federated authorities, which can result in an asymmetric hospital landscape with a potentially better distribution of clinical services in the Flanders hospital collaborations than in the other federated entities; and (2) the current regulations stipulate that only hospitals (and not networks) are entitled to hospital budgets. Although the reform is the most significant and drastic transformation of the Belgian hospital sector in the last three decades, networks mainly offer a framework in which hospitals can collaborate. More regulation and policy measures are needed to enhance collaboration and distribution of clinical services. ispartof: HEALTH POLICY vol:123 issue:7 pages:601-605 ispartof: location:Ireland status: published

Total hip replacement surgery is the mainstay of treatment for end-stage hip arthritis. In 2014, there were 28227 procedures (incidence rate 252/100000 population). Using administrative data, we projected the future volume of total hip replacement procedures and incidence rates using two models. The constant rate model fixes utilisation rates at 2014 levels and adjusts for demographic changes. Projections indicate 32248 admissions by 2025 or an annual growth of 1.22% (incidence rate 273). The time trend model additionally projects the evolution in age-specific utilisation rates. 34895 admissions are projected by 2025 or an annual growth of 1.95% (incidence rate 296). The projections show a shift in performing procedures at younger age. Forecasts of length of stay indicate a substantial shortening. By 2025, the required number of hospital beds will be halved. Despite more procedures, capacity can be reduced, leading to organisational change (e.g. elective orthopaedic clinics) and more labour intensive stays.

Objective The association between higher registered nurses (RN) staffing (educational level and number) and better patient and nurse outcomes is well-documented. This discussion paper aims to provide an overview of safe staffing policies in various high-income countries to identify reform trends in response to recurring nurse workforce challenges. Methods Based on a scan of the literature five cases were selected: England (UK), Ireland, California (USA), Victoria and Queensland (Australia). Information was gathered via a review of the grey and peer-reviewed literature. Country experts were consulted for additional information and to review country reports. Results The focus of safe staffing policies varies: increasing transparency about staffing decisions (England), matching actual and required staffing levels based on patient acuity measurement (Ireland), mandated patient-to-nurse ratios at the level of the nurse (California) or the ward (Victoria, Queensland). Calibration of the number of patients by the number of nurses varies across cases. Nevertheless, positive effects on the nursing workforce (increased bedside staffing) and staff well-being (increased job satisfaction) have been consistently documented. The impact on patient outcomes is promising but less well evidenced. Conclusion Countries will have to set safe staffing policies to tackle challenges such as the ageing population and workforce shortages. Various approaches may prove effective, but need to be accompanied by a comprehensive policy that enhances bedside nurse staffing in an evidence-based, objective and transparent way.

In light of the international evolutions to establish inclusive trauma systems and to concentrate the care for the most severely injured in major trauma centres, we evaluated the degree of dispersion of trauma care in Belgium. We used descriptive statistics to illustrate the dispersion of major trauma care in Belgium based on two independent administrative databases: the registry of Mobile Intensive Care Units (2009–2015) and the Belgian Hospital Discharge Dataset (2009–2014). Patients with a severe trauma (n = 3856 in 2015) were transported towards 145 different hospital sites (on a total of 198 hospital sites) resulting in a median of 17 cases per hospital site (min = 1; P25 = 4; P75 = 30; max = 165). A minority of major trauma patients is after admission transferred to another hospital (8%) with a median of 10 days after admission to the hospital (IQR 3.5–24). The dispersion of care for major trauma patients in Belgium is so high that a reorganisation of care for severe injured patients in major trauma centres concentrating professional expertise and specialised equipment is recommended to guarantee a high quality of care in a qualitative and sustainable way.

Background In the last decades, day surgery has steadily and significantly grown in many countries, yet the increase has been uneven. There are large variations in day-surgery activity between countries, but also within countries between hospitals and surgeons. This paper explores the variability in day-care activity for elective surgical procedures between Belgian hospitals. Materials and methods The administrative hospital data of all patients formally admitted in a Belgian hospital for inpatient or day-care surgery between 2011 and 2013 were analysed and summarized in graphs. During 11 expert meetings with ad-hoc surgical expert groups the variability in day-surgery share between hospitals was discussed in depth. Results The variability in day-care share between Belgian hospitals is considerable. For 37 out of 486 elective surgical procedures, the variability ranged between 0 and 100%. High national day-care rates do not preclude room for improvement for certain hospitals as for the majority of these procedures there are "low performers". According to the consulted clinical experts, the high variability in day-care share may for the greater part be explained by medical team related factors, customs and traditions, the lack of clinical guidelines, financial factors, organisational factors and patient related factors. Conclusion If a further expansion of day surgery is envisaged in Belgium the factors that contribute to the current variability in day-surgery rates between hospitals should be addressed. In addition, a feedback system in which hospitals and health care providers have the figures on their percentage of procedures carried out in day surgery compared to other hospitals and care providers (benchmarking) and the monitoring of a number of quality indicators (e.g. unplanned readmission, unplanned inpatient stay, emergency department visit) should be installed.

Internationally the number of emergency department (ED) visits is on the rise while evidence suggests that a substantial proportion of these patients do not require emergency care but primary care. This paper presents the Belgian 2016 proposal for the reorganisation of urgent care provision and places it into its political context. The proposal focused on re-designing patient flow aiming to reduce inappropriate ED visits by improving guidance of patients through the system. Initially policymakers envisaged, as cornerstone of the reform, to roll-out as standard model the co-location of primary care centres and EDs. Yet, this was substantially toned down in the final policy decisions mainly because GPs strongly opposed this model (because of increased workload and loss of autonomy, hospital-centrism, etc.). In fact, the final compromise assures a great degree of autonomy for GPs in organising out-of-hours care. Therefore, improvements will depend on future developments in the field and continuous monitoring of (un-)intended effects is certainly indicated. This policy process makes clear how important it is to involve all relevant stakeholders as early as possible in the development of a reform proposal to take into account their concerns, to illustrate the benefits of the reform and ultimately to gain buy-in for the reform.

Objective To describe policy interventions that have the objective to reduce ED use and to estimate their effectiveness. Methods Narrative review by searching three electronic databases for scientific literature review papers published between 2010 and October 2015. The quality of the included studies was assessed with AMSTAR, and a narrative synthesis of the retrieved papers was applied. Results Twenty-three included publications described six types of interventions: (1) cost sharing; (2) strengthening primary care; (3) pre-hospital diversion (including telephone triage); (4) coordination; (5) education and self-management support; (6) barriers to access emergency departments. The high number of interventions, the divergent methods used to measure outcomes and the different populations complicate their evaluation. Although approximately two-thirds of the primary studies showed reductions in ED use for most interventions the evidence showed contradictory results. Conclusion Despite numerous publications, evidence about the effectiveness of interventions that aim to reduce ED use remains insufficient. Studies on more homogeneous patient groups with a clearly described intervention and control group are needed to determine for which specific target group what type of intervention is most successful and how the intervention should be designed. The effective use of ED services in general is a complex and multi-factorial problem that requires integrated interventions that will have to be adapted to the specific context of a country with a feedback system to monitor its (un-)intended consequences. Yet, the co-location of GP posts and emergency departments seems together with the introduction of telephone triage systems the preferred interventions to reduce inappropriate ED visits while case-management might reduce the number of ED attendances by frequent ED users.

Background We examine the implications of reducing the average length of stay (ALOS) for a delivery on the required capacity in terms of service volume and maternity beds in Belgium, using administrative data covering all inpatient stays in Belgian general hospitals over the period 2003–2014. Methods A projection model generates forecasts of all inpatient and day-care services with a time horizon of 2025. It adjusts the observed hospital use in 2014 to the combined effect of three evolutions: the change in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates. In addition, we develop an alternative scenario to evaluate the impact of an accelerated reduction of ALOS. Results Between 2014 and 2025, we expect the number of deliveries to increase by 4.41%, and the number of stays in maternity services by 3.38%. At the same time, a reduction in ALOS is projected for all types of deliveries. The required capacity for maternity beds will decrease by 17%. In case of an accelerated reduction of the ALOS to reach international standards, this required capacity for maternity beds will decrease by more than 30%. Conclusions Despite an expected increase in the number of deliveries, future hospital capacity in terms of maternity beds can be considerably reduced in Belgium, due to the continuing reduction of ALOS. Electronic supplementary material The online version of this article (10.1186/s12913-019-4500-8) contains supplementary material, which is available to authorized users.

Evaluate the impact of population ageing on the required hospital capacity. As the general population is ageing, the hospital population is also ageing. Additional capacity needs can initially be counterbalanced by reductions in length of stay. Population ageing starts to peak from 2030 with additional hospital capacity needs: inpatient days (+ 21.9%) and hospital beds (+ 21.1%). Investments in hospital alternatives as well as in geriatric expertise within hospitals are required to deal with the ageing population. In this study, we evaluate the impact of population ageing on the required hospital capacity. We used hospital discharge (years 2003–2014) and population data to estimate the required hospital capacity by 2025 for older inpatients (≥ 75 years) taking into account population changes and trends in hospital admission rates and length of stay. In addition, we developed an alternative scenario to evaluate the impact of accelerated ageing based on the peaks in population ageing from 2030 onwards. The number of inpatient stays for our study population is expected to increase from 478,027 in 2014 to 590,313 in 2025 (+ 23.5%). The average length of stay is expected to decrease by 18.4% (− 2.3 days). As a consequence, the number of inpatient days and the required bed capacity will only increase by 42,709 days (+ 0.7%) and 72 beds (+ 0.4%), respectively. The accelerated ageing scenario shows that the increase between 2014 and 2025 is more pronounced for inpatient stays (+ 50.5%), inpatient days (+ 21.9%) and hospital beds (+ 21.1%). Ageing will, if no drastic policy actions are taken, impact the required hospital capacity. This can initially (by 2025) be more or less controlled by further reductions in length of stay. From 2030, it is expected that the required hospital bed capacity will increase exponentially with a pronounced shift between general acute care beds towards geriatric and chronic care beds. If policy makers want to revert this trend, substantial investments in hospital alternatives will be required.

Objectify the hospital capacity use of patients with dementia. Patients with dementia were mostly admitted through the emergency department and their in-hospital mortality was high in the first days of admission. They had longer lengths of stay than other patients of the same age admitted for the same pathologies, and they stayed even longer when admitted from home and discharged to a residential care facility. Inappropriate hospital admission policy of patients with dementia calls for investments in adequate capacity, workforce and the development of geriatric expertise in the Belgian hospital sector, the residential care setting and in community care. Considering the limited information available, the aim of the study was to examine the prevalence and characteristics of inpatients with dementia in Belgian general hospitals. All admissions of inpatients aged at least 40 years with or without dementia were retrieved from the nationwide administrative hospital discharges database for the period 2010–2014. Admissions of inpatients aged 40 years or more with dementia have increased to reach 83,017 out of 1,285,593 admissions (6.46%) in general hospitals in 2014, mostly admitted through the emergency department (79.7%) and for another reason than dementia (85.9%). These patients stayed longer [19.2 days, standard deviation (sd) = 23.6, median = 13] than the average length of stay of patients of the same age (7.9 days, sd = 14.1, median = 17). Considering patients aged 75 years or more falling into the 20 most common pathology groups (of patients with dementia), the group with dementia spent 5 days more than the group without dementia. Patients admitted from home spent more time in hospital when they were discharged to a residential care facility than when they returned home (27.2 days versus 15.8 days). The in-hospital mortality was high in the first days of admission. The growing prevalence of patients with dementia in inpatient setting puts a high pressure on the hospital capacity planning and geriatric expertise. Moreover, as patients with dementia should be kept outside hospitals when possible for safety and quality matters, long-term organizational investments are required inside hospital and residential care settings as well as in community care.

Context Financial challenges and the need for high-quality care have vastly increased the number of hospital collaborations in recent decades. The governance of these collaborations remains a challenge. The goal of this study is twofold: (1) to investigate the governance characteristics in an interhospital collaboration and (2) explore the impact on the performance of the interhospital collaboration. Methods A systematic review was conducted to provide a comprehensive overview of the evidence on governance in interhospital collaborations. Database searches yielded 9304 candidate articles, of which 26 studies fulfilled the inclusion criteria. Findings Governance in collaborations differs in collaboration structure, governance characteristics and contextual factors. Although outcome factors are influenced by contextual determinants and the collaboration structure itself, governance characteristics are of great importance. Conclusions A critical challenge for managers is to successfully adapt collaborations structures and governance characteristics to rapidly changing conditions. Policy makers should ensure that new legislation and guidelines for internal governance can be adapted to different contextual factors. Research in the future should investigate the impact of governance as a dynamic process. More longitudinal case study research is needed to provide an in-depth view of the relationship between this process and the performance of a collaboration.

Background Hospitals are increasingly parts of larger care collaborations, rather than individual entities. Organizing and operating these collaborations is challenging; a significant number do not succeed, as it is difficult to align the goals of the partners. However, little research has focused on stakeholders’ views regarding hospital collaboration models or on whether these views are aligned with those of hospital management. This study explores Belgian hospital stakeholders’ views on the factors affecting hospital collaborations and their perspectives on different models for Belgian interhospital collaboration. Methods Qualitative focus group study on the viewpoints, barriers, and facilitators associated with hospital collaboration models (health system, network, joint venture). Results A total of 55 hospital stakeholders (hospital managers, chairs of medical councils, chair of hospital boards and special interest groups) participated in seven focus group sessions. Collaboration in health care is challenging, as the goals of the different stakeholder groups are partly parallel but also sometimes conflicting. Hospital managers and special interest groups favored health systems as the most integrated form. Hospital board members also opted for this model, but believed a coordinated network to be the most pragmatic and feasible model at the moment. Members of physicians’ organizations preferred the joint venture, as it creates more flexibility for physicians. Successful collaboration requires trust and commitment. Legislation must provide a supporting framework and governance models. Conclusions Involvement of all stakeholder groups in the process of decision-making within the collaboration is perceived as a necessity, which confirms the importance of the stakeholders’ theory. The health system is the collaboration structure best suited to enhancing task distribution and improving patient quality. However, the existence of networks and joint ventures is considered necessary in the process of transformation towards more solid hospital collaborations such as health systems. Electronic supplementary material The online version of this article (10.1186/s12913-018-3763-9) contains supplementary material, which is available to authorized users.

Objectives This study aims to identify the facilitators and barriers to governance models of hospital collaborations. The country-specific characteristics of the Belgian healthcare system and legislation are taken into account. Methods A case study was carried out in six Belgian hospital collaborations. Different types of governance models were selected: two health systems, two participant-governed networks, and two lead-organization-governed networks. Within these collaborations, 43 people were interviewed. Results All structures have both advantages and disadvantages. It is important that the governance model fits the network. However, structural, procedural, and especially contextual factors also affect the collaborations, such as alignment of hospitals' and professionals' goals, competition, distance, level of integrated care, time needed for decision-making, and legal and financial incentives. Conclusion The fit between the governance model and the collaboration can facilitate the functioning of a collaboration. The main barriers we identified are contextual factors. The Belgian government needs to play a major role in facilitating collaboration.

Objectives To compare projected and observed hospital inpatient use in Belgium and to draw lessons from that comparison. Methods In 2005, projections for hospital service use were generated up to 2015, based on demographic change, substitution from inpatient to day care, and, the evolution of the average length of stay (LOS). The accuracy of the forecasts was assessed by comparing projected and observed population size, admissions and inpatient days, average LOS and percentage change in case mix. Results The demographic growth was underestimated. Overall, the baseline projection for hospital admissions was remarkably close to the observed figures but the underlying case mix diverged importantly. With substitution between inpatient and day care, the number of admissions was underestimated by 15%–40%. The number of days was projected to increase in every scenario, whereas a decreasing trend was observed mainly due to the faster decline in average LOS than projected. Conclusion Hospital capacity planning is an important component of evidence informed policymaking. Projection results benefit from a well-designed methodology: choice of forecast groups, estimation models, selection criteria, and a sensitivity analysis of the results. To cope with the dynamic and continuously evolving context in which hospitals operate, regular updates to incorporate new data and to reassess estimated trends should be an integral part of the projection framework.

The prevalence of mental health problems among children and adolescents in Western countries is high. Belgium, like many other Western countries, struggles with the set-up of a coherent and effective strategy for dealing with this complex societal problem. This paper describes the development of a policy scenario for the organization of child and adolescent mental health care services (CAMHS) in Belgium. The development process relied on Soft Systems Methodology including a participatory process with 66 stakeholders and a review of the existing (inter-)national evidence. A diagnostic analysis illustrated that the Belgian CAMHS is a system in serious trouble characterized by fragmentation and compartmentalization. A set of 10 strategic recommendations was formulated to lay down the contours of a future, more effective CAMHS system. They focus on mastering the demands made on scarce and expensive specialized mental health services; strengthening the range of services - in particular for those with serious, complex and multiple mental health problems - and strengthening the adaptive capacity of and the ethical guidance within the future CAMHS system.

Purpose Evidence suggests that patients who gain knowledge perform better self-care, cope better and are more satisfied. Today, up-to-date and valid instruments for evaluating patient knowledge on chemotherapy are unavailable. Hence, our aim was to develop a valid instrument to assess patients' knowledge on chemotherapy. Method We performed a literature review to develop a topic list for the construct. Using a triple Delphi procedure, an expert panel of nine oncologists and oncology nurses evaluated the face and content validity of the topic list and the generated items. A preliminary psychometric evaluation of 144 patients allowed to identify and remediate items having limited applicability and item validity. A convenience sample of 440 patients was used to evaluate item statistics (item difficulty), reliability (Cronbach alpha) and construct validity (exploratory factor analysis) of the final instrument. Results We developed a 20-item instrument reflecting 14 relevant themes of patient knowledge on chemotherapy in 13 questions. Twelve items cover general chemotherapy aspects, eight items cover treatment-specific knowledge. Three questions are facultative and address oral chemotherapy. Content validity was excellent (CVI = 0.78–1.00). Item difficulty ranged from 0.25 to 0.95. Internal consistency was acceptable (Cronbach's alpha = 0.67). Exploratory factor analysis defined four underlying factors: general aspects of chemotherapy treatment, negative treatment-related events, information resources and intake of oral chemotherapy. Conclusions The Leuven Questionnaire on Patient Knowledge of Chemotherapy (L-PaKC) demonstrated good content validity and psychometric properties, permitting application in both research and practice for evaluating patient knowledge on chemotherapy.

Purpose Since chemotherapy has largely become an outpatient treatment, adequate self-management is of great importance. Available instruments focus exclusively on dealing with side effects. However, self-care during chemotherapy not only concerns symptom self-management. The aim of this study was to develop a valid instrument to assess patient self-care during chemotherapy. Method First, we developed a topic list for our construct by performing a theory and literature review. Second, an expert panel of nine oncologists and oncology nurses evaluated content validity of the developing construct and its items using a triple Delphi procedure. A preliminary psychometric evaluation in 144 patients allowed identification and correction of items with poor psychometric properties. A convenience sample of 448 patients was used to evaluate item statistics (item difficulty), reliability (Cronbach alpha) and construct validity (exploratory factor analysis) of the final instrument. Results We developed a 22-item instrument with 7 themes expressing the most relevant aspects of patient self-care during chemotherapy. Seven items cover symptom self-management, while 15 items reflect other aspects of self-care during chemotherapy. Content validity was excellent (CVI = 0.78–1.00). Item difficulty index of the questions ranged from 0.17 to 0.89. Internal consistency is acceptable (Cronbach alpha = 0.76). Exploratory factor analysis defines two underlying factors: adhering to treatment recommendations and managing treatment-related negative events on the one hand, and relieving symptoms on the other hand. Conclusions The L-PaSC demonstrated good content validity and psychometric properties. The L-PaSC can be applied in research and clinical practice for evaluating patient self-care during chemotherapy.

Summary We explore health outcomes and nurse staffing data that are multivariate multilevel structured. These data can be used to relate latent constructs such as patient safety to hospital, nursing unit, nurse and patient characteristics by using factor analytic models. It is important that the multilevel nature of the data is taken into account; otherwise it can lead to invalid inferences. We explore the relationship between patient safety and nurse-reported adverse events from the Belgian chapter of the Europe Nurse Forecasting Survey. The data were split into a learning and a validation data set. Since no a priori factor structure has been proposed in the literature, we establish the factor structure by using a frequentist exploratory factor analysis on the learning data set and validate the factor structure proposed by using a Bayesian confirmatory factor analysis on the validation data set. Multivariate analysis-of-variance discrepancy measures were used to assess the need for multilevel factor analysis. We establish that there was substantial between-nursing-unit, but not between-hospital, variability to warrant the use of multilevel factor analyses. The final model was a two-level (nurse level and nursing unit level) factor analytic model with two factors at both levels. The Bayesian approach offers more flexibility in fitting the multilevel confirmatory factor analysis. To avoid double usage of the data the validation and learning data sets were used to fit and assess the goodness of fit of the multilevel confirmatory factor analysis respectively.

The realization of an organizational context that succeeds to retain nurses within their job is one of the most effective strategies of dealing with nursing shortages.First, to examine the impact of nursing practice environments, nurse staffing and nurse education on nurse reported intention to leave the hospital. Second, to provide understanding of which best practices in the organization of nursing care are being implemented to provide sound practice environments and to retain nurses.3186 bedside nurses of 272 randomly selected nursing units in 56 Belgian acute hospitals were surveyed. A GEE logistic regression analysis was used to estimate the impact of organization of nursing care on nurse reported intention to leave controlling for differences in region (Walloon, Flanders, and Brussels), hospital characteristics (technology level, teaching status, and size) and nurse characteristics (experience, gender, and age). For the second objective, in-depth semi-structured interviews with the chief nursing officers of the three high and three low performing hospitals on reported intention to leave were held.29.5% of Belgian nurses have an intention-to-leave the hospital. Patient-to-nurse staffing ratios and nurse work environments are significantly (p0.05) associated with intention-to-leave. Interviews with Chief Nurse Officers revealed that high performing hospitals showing low nurse retention were--in contrast to the low performing hospitals--characterized by a flat organization structure with a participative management style, structured education programs and career opportunities for nurses.This study, together with the international body of evidence, suggests that investing in improved nursing work environments is a key strategy to retain nurses.

Background Several studies have concluded that the use of nurses' time and energy is often not optimized. Given widespread migration of nurses from developing to developed countries, it is important for human resource planning to know whether nursing education in developing countries is associated with more exaggerated patterns of inefficiency. Objectives First, to describe nurses' reports on tasks below their skill level. Second, to examine the association between nurses' migratory status (domestically trained nurse or foreign trained nurse from a developing country) and reports on these tasks. Design The Registered Nurse Forecasting Study used a cross-sectional quantitative research design to gather data from 33,731 nurses (62% response rate) in 486 hospitals in Belgium, England, Finland, Germany, Greece, Ireland, the Netherlands, Norway, Poland, Spain, Sweden and Switzerland. Methods For this analysis, nurse-reported information on migratory status and tasks below their skill level performed during their last shift was used. Random effects models estimated the effect of nurses' migratory status on reports of these tasks. Results 832 nurses were trained in a developing country (2.5% of total sample). Across countries, a high proportion of both domestically trained and foreign trained nurses from developing countries reported having performed tasks below their skill level during their last shift. After adjusting for nurses' type of last shift worked, years of experience, and level of education, there remained a pronounced overall effect of being a foreign trained nurse from a developing country and an increase in reports of tasks below skill level performed during the last shift. Conclusion The findings suggest that there remains much room for improvement to optimize the use of nurses' time and energy. Special attention should be given to raising the professional level of practice of foreign trained nurses from developing countries. Further research is needed to understand the influence of professional practice standards, skill levels of foreign trained nurses from developing countries and values attached to these tasks resulting from previous work experiences in their home countries. This will allow us to better understand the conditions under which foreign trained nurses from developing countries can optimally contribute to professional nursing practice in developed country contexts.

Objective. To describe the systematic language translation and cross-cultural evaluation process that assessed the relevance of the Hospital Consumer Assessment of Healthcare Providers and Systems survey in five European countries prior to national data collection efforts. Design. An approach involving a systematic translation process, expert review by experienced researchers and a review by ‘patient’ experts involving the use of content validity indexing techniques with chance correction. Setting. Five European countries where Dutch, Finnish, French, German, Greek, Italian and Polish are spoken. Participants. ‘Patient’ experts who had recently experienced a hospitalization in the participating country. Main OutcomeMeasure(s). Content validity indexing with chance correction adjustment providing a quantifiable measure that evaluates the conceptual, contextual, content, semantic and technical equivalence of the instrument in relationship to the patient care experience. Results. All translations except two received ‘excellent’ ratings and no significant differences existed between scores for languages spoken in more than one country. Patient raters across all countries expressed different concerns about some of the demographic questions and their relevance for evaluating patient satisfaction. Removing demographic questions from the evaluation produced a significant improvement in the scale-level scores (P ¼ .018). The cross-cultural evaluation process suggested that translations and content of the patient satisfaction survey were relevant across countries and languages. Conclusions. The Hospital Consumer Assessment of Healthcare Providers and Systems survey is relevant to some European hospital systems and has the potential to produce internationally comparable patient satisfaction scores.

OBJECTIVE: The aim of the present study was to evaluate the association between illness perceptions and the ability to cope with physical and mental health problems in a large cohort of systemic sclerosis (SSc) patients. METHODS: This was a cross-sectional study in 217 systemic sclerosis patients from the Belgian Systemic Sclerosis Cohort. Illness perception and coping were measured by the Revised Illness Perception Questionnaire and a coping questionnaire - the Coping Orientation of Problem Experience inventory (COPE). Physical and mental health-related quality of life was measured by the 36-item short-form health survey (SF-36), as were disease activity and several severity parameters. The relationship between illness perceptions and the ability to cope with physical/mental health problems was examined using multiple linear regression analysis. RESULTS: According to LeRoy's classification, 49 patients had limited SSc (lSSc), 129 had limited cutaneous SSc (lcSSc) and 39 had diffuse cutaneous SSc (dcSSc). Median disease duration was five years and the modified Rodnan skin score was 4. Good physical health was significantly associated with the lcSSc subtype and low disease activity (p

diya l., van den heede k., sermeus w. & lesaffre e. (2011)The relationship between in-hospital mortality, readmission into the intensive care nursing unit and/or operating theatre and nurse staffing levels. Journal of Advanced Nursing00(0), 000-000. doi: 10.1111/j.1365-2648.2011.05812.x Aim. The aim of this article was to assess the relationship between (1) in-hospital mortality and/or (2) unplanned readmission to intensive care units or operating theatre and nurse staffing variables. Background. Adverse events are used as surrogates for patient safety in nurse staffing and patient safety research. A single adverse event cannot adequately capture the multi-dimensional attributes of patient safety; hence, there is a need to consider composite measures. Unplanned readmission into the postoperative Intensive Care nursing unit and/or operating Theatre and in-hospital mortality can be viewed as measures that incorporate the effects of several adverse events. Methods. We conducted a Bayesian multilevel analysis on a subset of the 2003 Belgian Hospital Discharge and Nursing Minimum Data sets. The sample included 9054 patients who underwent coronary artery bypass surgery or heart valve procedures from 28 Belgian acute hospitals. Two proxies of patient safety were considered, namely postoperative in-hospital mortality in the first postoperative intensive care unit and unplanned readmission into the intensive care and/or operating theatre (including mortality beyond the first postoperative intensive care unit) after the first-operative intensive care nursing unit. Results. There is an association between in-hospital mortality and/or unplanned readmissions and nurse staffing levels, but the relationship is moderated by volume and severity of illness respectively. In addition, the relationship differs between the two endpoints. Conclusion. Higher nurse staffing levels on postoperative general nursing cardiac surgery units protected patients from unplanned readmission to intensive care units or operating theatre and in-hospital mortality. © 2011 The Authors. Journal of Advanced Nursing

Purpose The aim of this study was to examine how patients recall symptoms at a delayed self-report. Accurate insight into toxicity symptoms during chemotherapy is essential so that nurses and doctors can assess therapeutic tolerance and adjust supportive care accordingly. Method A non-experimental, longitudinal design was employed. Using the Therapy-Related Symptoms Checklist (TRSC), respondents ( n = 142) reported their initial symptoms during the first 7 days of the chemotherapy cycle at two different times: (1) each day of the first seven days after the chemotherapy administration (immediate self-report), and (2) at their next hospital visit for chemotherapy (delayed self-report). We compared the number and severity of symptoms and side effects reported in the immediate and delayed self-reports. Results Respondents reported significantly fewer symptoms and fewer severe symptoms in the delayed self-report. For 22 out of 25 symptoms the delayed-reported grade was significantly lower than the immediate-reported maximum grade. Compared to the immediate-reported median grade, significant differences occurred in only 10 out of the 25 symptoms. In all cases, except fatigue, the delayed-reported grade was significantly higher than the immediate-reported median grade. Conclusions This study indicates that delayed self-report of chemotherapy side effects is not an appropriate measure of actual symptoms and side effects experienced by patients. Delayed self-report gives a weaker insight into actual symptom burden. Fatigue is at particular risk to be minimized at the delayed self-report. Therefore it is recommended to assess chemotherapy-related symptoms and side effects by means of immediate self-report.

Background: Lives saved predictions are used to quantify the impact of certain remedial measures in nurse staffing and patient safety research, giving an indication of the potential gain in patient safety. Data collected in nurse staffing and patient safety are often multilevel in structure, requiring statistical techniques to account for clustering in the data. Objective: The purpose of this study was to assess the impact of model specifications on lives saved estimates and inferences in a multilevel context. Methods: A simulation study was carried out to assess the impact of model assumptions on lives saved predictions. Scenarios considered were omitting an important covariate, taking different link functions, neglecting the correlations coming from the multilevel data structure, and neglecting a level in a multilevel model. Finally, using a cardiac surgery data set, predicted lives saved from the random intercept logistic model and the clustered discrete time logistic model were compared. Results: Omitting an important covariate, neglecting the association between patients within the same hospital, and the complexity of the model affect the prediction of lives saved estimates and the inferences thereafter. On the other hand, a change in the link function led to the same predicted lives saved estimates and standard deviations. Finally, the lives saved estimates from the two-level random intercept model were similar to those of the clustered discrete time logistic model, but the standard deviations differed greatly. Conclusions: The results stress the importance of verifying model assumptions. It is recommended that researchers use sensitivity analyses to investigate the stability of lives saved results using different statistical models or different data sets. Copyright

van den heede k., simoens s., diya l., lesaffre e., vleugels a. & sermeus w. (2010) Increasing nurse staffing levels in Belgian cardiac surgery centres: a cost-effective patient safety intervention? Journal of Advanced Nursing 66(6), 1291–1296. Abstract Title. Increasing nurse staffing levels in Belgian cardiac surgery centres: a cost-effective patient safety intervention?. Aim. This paper is a report of a cost-effectiveness analysis from a hospital perspective of increased nurse staffing levels (to the level of the 75th percentile) in Belgian general cardiac postoperative nursing units. Background. A previous study indicated that increasing nurse staffing levels in Belgian general cardiac postoperative nursing units was associated with lower mortality rates. Research is needed to compare the costs of increased nurse staffing levels with benefits of reducing mortality rates. Method. Two types of average national costs were compared. A first calculation included the simulation of an increase in the number of nursing hours per patient day to the 75th percentile for nursing units staffed below that level. For the second calculation (the comparator) we used a ‘do nothing’ alternative. The most recent available data sources were used for the analysis. Results were expressed in the form of the additional costs per avoided death and the additional costs per life-year gained. The analysis used 2007 costing data. Findings. The costs of increasing nurse staffing levels to the 75th percentile in Belgian general cardiac postoperative nursing units amounted to €1,211,022. Such nurse staffing levels would avoid an estimated number of 45·9 (95% confidence interval: 22·0–69·4) patient deaths per year and generate 458·86 (95% confidence interval: 219·93–693·79) life-years gained annually. This corresponds with incremental cost-effectiveness ratios of €26,372 per avoided death and €2639 per life-year gained. Conclusion. Increasing nurse staffing levels appears to be a cost-effective intervention as compared with other cardiovascular interventions.

Background: Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited. Objectives: This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelor's degree) and 10 different patient outcomes potentially sensitive to nursing care. Design-setting-participants: Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n = 1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n = 260,923) of the year 2003 from all acute hospitals (n = 115). Methods: Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes. Results: The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D. = 0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelor's degree and the selected patient outcomes. Conclusion: The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.

Rationale, aims and objectives Issues of overuse, underuse and misuse are paramount and lead to avoidable morbidity and mortality. Although evidence-based practice is advocated, the widespread implementation of this kind of practice remains a challenge. This is also the case for evidence-based practice related to the prevention of pressure ulcers, which varies widely in process and outcome in Belgian hospital care. One major obstacle to bridging this knowledge-to-action gap is data availability. We propose using large-scale hospital administrative data combined with the latest evidence-based methods as part of the solution to this problem. Method To test our proposal, we applied this approach to pressure ulcer prevention, using an administrative dataset with regard to 6030 patients in 22 Belgian hospitals as a sample of nationally available data. Methods include a systematic review approach, evidence grading, recommendations formulation, algorithm construction, programming of the rule set and application on the database. Results We found that Belgian hospitals frequently failed to provide appropriate prevention care. Significant levels of underuse, up to 28.4% in pressure ulcer prevention education and 17.5% in the use of dynamic systems mattresses, were detected. Figures for overuse were mostly not significant. Misuse couldn't be assessed. Conclusions These results demonstrate that this approach can indeed be successfully used to bridge the knowledge-to-action gap in medical practice, by implementing an innovative method to assess underuse and overuse in hospital care. The integrative use of administrative data and clinical applications should be replicated in other patient groups, other datasets and other countries.

Purpose: To study the predictive validity of the instrument used in the International Hospital Outcomes Study (IHOS) for an upcoming EU-funded project (RN4CAST), which will indicate the effect of the nursing work environment and nursing staff deployment on nurse recruitment, retention, and productivity; and on patient outcomes in 11 European countries. Methods: Cross-sectional analysis of data from 179 nurses (75% response rate) who completed an IHOS-like nurse survey questionnaire, which included the Revised Nursing Work Index and the Maslach Burnout Inventory. The nurses worked in four Belgian acute-care hospitals. Logistic regression modeling was performed to explore associations between nurse-perceived outcomes and nursing work environment factors that were checked with confirmatory factor analysis. Findings: We confirmed associations between nurse-perceived outcomes and the following nursing work environment factors: nurse-physician relationship; staffing, and resource adequacy; and nurse manager ability, leadership, and support of nurses. A 1-point increase in the rating of the factor nurse-physician relationship was significantly associated with a 2.5-fold (OR, 2.53; 95% CI, 1.29‐4.93; p

Background: In most multicenter studies that examine the relationship between nurse staffing and patient safety, nurse-staffing levels are measured per hospital. This can obscure relationships between staffing and outcomes at the unit level and lead to invalid inferences. Objective: In the present study, we examined the association between nurse-staffing levels in nursing units that treat postoperative cardiac surgery patients and the in-hospital mortality of these patients. Design-setting-participants: We illustrated our approach by using administrative databases (Year 2003) representing all Belgian cardiac centers (n = 28), which included data from 58 intensive care and 75 general nursing units and 9054 patients. Methods: We used multilevel logistic regression models and controlled for differences in patient characteristics, nursing care intensity, and cardiac procedural volume. Results: Increased nurse staffing in postoperative general nursing units was significantly associated with decreased mortality. Nurse staffing in postoperative intensive care units was not significantly associated with in-hospital mortality possibly due to lack of variation in ICU staffing across hospitals. Conclusion: This study, together with the international body of evidence, suggests that nurse staffing is one of several variables influencing patient safety. These findings further suggest the need to study the impact of nurse-staffing levels on in-hospital mortality using nursing-unit-level specific data.

Purpose: To assess the key variables used in research on nurse staffing and patient outcomes from the perspective of an international panel. Design: A Delphi survey (November 2005-February 2006) of a purposively-selected expert panel from 10 countries consisting of 24 researchers specializing in nurse staffing and quality of health care and 8 nurse administrators. Methods: Each participant was sent by e-mail an up-to-date review of all evidence related to 39 patient-outcome, 14 nurse-staffing and 31 background variables and asked to rate the importance/usefulness of each variable for research on nurse staffing and patient outcomes. In two subsequent rounds the group median, mode, frequencies, and earlier responses were sent to each respondent. Findings: Twenty-nine participants responded to the first round (90.6%), of whom 28 (87.5%) responded to the second round. The Delphi panel generated 7 patient-outcome, 2 nurse-staffing and 12 background variables in the first round, not well-investigated in previous research, to be added to the list. At the end of the second round the predefined level of consensus (85%) was reached for 32 patient outcomes, 10 nurse staffing measures and 29 background variables. The highest consensus levels regarding measure sensitivity to nurse staffing were found for nurse perceived quality of care, patient satisfaction and pain, and the lowest for renal failure, cardiac failure, and central nervous system complications. Nursing Hours per Patient Day received the highest consensus score as a valid measure of the number of nursing staff. As a skill mix variable the proportion of RNs to total nursing staff achieved the highest consensus level. Both age and comorbidities were rated as important background variables by all the respondents. Conclusions: These results provide a snapshot of the state of the science on nurse-staffing and patient-outcomes research as of 2005. The results portray an area of nursing science in evolution and an understanding of the connections between human resource issues and healthcare quality based on both empirical findings and opinion.

Background In most Western countries burn centres have been developed to provide acute and critical care for patients with severe burn injuries. Nowadays, those patients have a realistic chance of survival. However severe burn injuries do have a devastating effect on all aspects of a person’s life. Therefore a well-organized and specialized aftercare system is needed to enable burn patients to live with a major bodily change. The aim of this study is to identify the problems and unmet care needs of patients with severe burn injuries throughout the aftercare process, both from patient and health care professional perspectives in Belgium. Methods By means of face-to-face interviews (n = 40) with individual patients, responsible physicians and patient organizations, current experiences with the aftercare process were explored. Additionally, allied healthcare professionals (n = 17) were interviewed in focus groups. Results Belgian burn patients indicate they would benefit from a more integrated aftercare process. Quality of care is often not structurally embedded, but depends on the good intentions of local health professionals. Most burn centres do not have a written discharge protocol including an individual patient-centred care plan, accessible to all caregivers involved. Patients reported discontinuity of care: nurses working at general wards or rehabilitation units are not specifically trained for burn injuries, which sometimes leads to mistakes or contradictory information transmission. Also professionals providing home care are often not trained for the care of burn injuries. Some have to be instructed by the patient, others go to the burn centre to learn the right skills. Finally, patients themselves underestimate the chronic character of burn injuries, especially at the beginning of the care process. Conclusions The variability in aftercare processes and structures, as well as the failure to implement locally developed best-practices on a wider scale emphasize the need for a comprehensive network, which can initiate transversal activities such as the development of discharge protocols, common guidelines, and quality criteria.

Background and objectives Interdisciplinary geriatric consultation teams are implemented in the acute hospital setting in several high-income countries to provide comprehensive geriatric assessment for the increasing numbers of older patients with a geriatric profile hospitalized on non-geriatric units. Given the inconclusive evidence on this care model's effectiveness to improve patient outcomes, health care policy and practice oriented recommendations to redesign the structure and process of care provided by interdisciplinary geriatric consultation teams are needed. A scoping review was conducted to explore the structure and processes of interdisciplinary geriatric consultation teams in an international context. As nurses are considered key members of these teams, their roles and responsibilities were specifically explored. Design The revised scoping methodology framework of Arksey and O'Malley was applied. Data sources An electronic database search in Ovid MEDLINE, CINAHL and EMBASE and a hand search were performed for the identification of descriptive and experimental studies published in English, French or Dutch until April 2014. Review methods Thematic reporting with descriptive statistics was performed and study findings were validated through interdisciplinary expert meetings. Results Forty-six papers reporting on 25 distinct interdisciplinary geriatric consultation teams in eight countries across three continents were included. Eight of the 12 teams (67%) reporting on their composition, stated that nurses and physicians were the main core members with head counts varying from 1 to 4 members per profession. In 80% of these teams nurses were required to have completed training in geriatrics. Advanced practice nurses were integrated in eleven out of fourteen interdisciplinary geriatric consultation teams from the USA. Only 32% of teams used formal screening to identify patients most likely to benefit from their intervention, using heterogeneous screening methods, and scarcely providing information on the responsibilities of nurses. Nurses were involved in the medical, functional, psychological and social assessment of patients in 68% of teams, either in a leading role or in collaboration with other professions. Responsibilities of interdisciplinary geriatric consultation teams' nurses regarding in-hospital follow-up or transitional care at hospital discharge were infrequently specified (16% of teams). Conclusions This scoping review identified that the structure and processes of care provided to geriatric patients by interdisciplinary geriatric consultation teams are highly heterogeneous. Despite nurses being key team members, only limited information on their specific roles and responsibilities was identified. More research in this area is required in order to inform health care policy and to formulate practice oriented recommendations to redesign the interdisciplinary geriatric consultation team care model aiming to improve its effectiveness.

Objective. The prevalence and variability of adverse outcome rates in Belgian acute hospitals is examined by using the national hospital discharge database. Design, setting, and participants. Retrospective analysis based on administrative data of all Belgian acute hospitals, covering the full medical (n = 1 024 743) and surgical (n = 633 027) in-patients population for the year 2000. Main outcome measures. For 11 adverse outcomes and failure-to-rescue, the rates and variability among hospitals were studied. The all patient refined diagnostic-related groups (APR-DRG) method was used for risk adjustment. Results. The prevalence of adverse outcomes was 7.12% in the medical and 6.32% in the surgical group. Rates ranged from 6.25 (deep venous thrombosis) to 32.3 (urinary tract infection) outcomes per 1000 discharges in the medical group and from 3.39 (deep venous thrombosis) to 17.6 (urinary tract infection) outcomes per 1000 discharges in the surgical group. The failureto-rescue rate was 240 and 211 per 1000 discharges, respectively. Except for pressure ulcers and hospital-acquired sepsis, the prevalence of adverse outcomes was significantly higher (P = 0.001) in the medical group. All adverse outcome rates varied substantially among the hospitals surveyed. Conclusions. This study identifies the occurrence of adverse outcomes in a national population. It adds information to the growing body of knowledge in predominantly Anglo-Saxon countries about adverse outcomes. Striking variation exists in the risk-adjusted adverse outcome rates across Belgian acute hospitals, revealing a large potential for quality gains that encourage further action.

Background Despite a high prevalence of mental health problems among children and adolescents Belgium, like many other Western countries, does not have a clear strategy for the organization of child and adolescent mental healthcare services (CAMHS). Methods This paper describes stakeholders’ views on the organization of CAMHS based on a qualitative study. Ten in-depth interviews with high profile stakeholders were complemented by roundtable discussions (n = 30). Results This diagnostic analysis illustrated that the system is in serious trouble characterized by fragmentation and compartmentalization. Conclusion The findings create a sense of urgency that should be used to initiate a system reform of the Belgian CAMHS system.

PurposeThe purpose of this article is to assess the reliability of an in‐depth analysis on causation, preventability, and disability by two separate review teams on five selected adverse events in acute hospitals: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator‐associated pneumonia and postoperative wound infection.Design/methodology/approachThe analysis uses a retrospective medical record review of 1,515 patient records by two independent teams in eight acute Belgian hospitals for the year 2005. The Mann‐Whitney U‐test is used to identify significant differences between the two review teams regarding occurrence of adverse events as well as regarding the degree of causation, preventability, and disability of found adverse events.FindingsTeam 1 stated a high probability for health care management causation in 95.5 per cent of adverse events in contrast to 38.9 per cent by Team 2. Likewise, high preventability was considered in 83.1 per cent of cases by Team 1 versus 51.7 per cent by Team 2. Significant differences in degree of disability between the two teams were also found for pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis and postoperative wound infection, but not for postoperative sepsis and ventilator‐associated pneumonia.Originality/valueNew insight on the degree of and reasons for the huge differences in adverse event evaluation is provided.

Item does not contain fulltext BACKGROUND: As health services research (HSR) expands across the globe, researchers will adopt health services and health worker evaluation instruments developed in one country for use in another. This paper explores the cross-cultural methodological challenges involved in translating HSR in the language and context of different health systems. OBJECTIVES: To describe the pre-data collection systematic translation process used in a twelve country, eleven language nursing workforce survey. DESIGN AND SETTINGS: We illustrate the potential advantages of Content Validity Indexing (CVI) techniques to validate a nursing workforce survey developed for RN4CAST, a twelve country (Belgium, England, Finland, Germany, Greece, Ireland, Netherlands, Norway, Poland, Spain, Sweden, and Switzerland), eleven language (with modifications for regional dialects, including Dutch, English, Finnish, French, German, Greek, Italian, Norwegian, Polish, Spanish, and Swedish), comparative nursing workforce study in Europe. PARTICIPANTS: Expert review panels comprised of practicing nurses from twelve European countries who evaluated cross-cultural relevance, including translation, of a nursing workforce survey instrument developed by experts in the field. METHODS: The method described in this paper used Content Validity Indexing (CVI) techniques with chance correction and provides researchers with a systematic approach for standardizing language translation processes while simultaneously evaluating the cross-cultural applicability of a survey instrument in the new context. RESULTS: The cross-cultural evaluation process produced CVI scores for the instrument ranging from .61 to .95. The process successfully identified potentially problematic survey items and errors with translation. CONCLUSIONS: The translation approach described here may help researchers reduce threats to data validity and improve instrument reliability in multinational health services research studies involving comparisons across health systems and language translation.

The management of chronic diseases is a prime challenge of most 21st century health care systems. Many Western countries have invested heavily in care plans oriented towards specific conditions and diseases, such as dementia and cancer. The major downside of this narrowly focused approach is that treatment of multimorbidity is ignored. This paper describes the development and main stance of a national position that proposes streamlined reforms of the Belgian health care system to improve care for patients with multiple chronic diseases. We used a combination of methods to develop this stance: literature review and stakeholders’ consultation. The latter identified areas for improvement: efficiency of the health care system, coordination of care, investments in human care resources, informal caregivers’ support, better accessibility, and changes in the financial payment system. The position paper list 20 recommendations that are translated into about 50 action points to reform the health care system. Chronic care tailored to the patient's needs, including implementation of multidisciplinary teamwork, new functions, task delegation in primary care, and empowerment of the patient and informal caregivers are some major areas discussed. In addition, improved support, revised payment mechanisms, and setting up a quality system, along with the tailoring of patient care, can all facilitate delivery of high quality care in patients with chronic comorbidities.

Cost containment pressures underscore the need to better understand how nursing resources can be optimally configured.To obtain a snapshot of European nurses' assessments of their hospital work environments and quality of care in order to identify promising strategies to retain nurses in hospital practice and to avoid quality of care erosions related to cost containment.Cross sectional surveys of 33,659 hospital medical-surgical nurses in 12 European countries.Surveyed nurses provided care in 488 hospitals in Belgium, England, Finland, Germany, Greece, Ireland, the Netherlands, Norway, Poland, Spain, Sweden, and Switzerland.All nurses were surveyed from medical-surgical units 30 or more hospitals from geographically representative samples of hospitals in each country, except for Ireland and Norway, where all hospitals were selected, and Sweden, where nearly all hospitals were included by sampling all medical-surgical nurses who were members of the Swedish Nursing Association.Percentages are provided for each of the nurse and hospital characteristics reported.There was wide variation across countries in the percentages of hospital nurses that were bachelor's prepared (range 0-100%), in patient to nurse average workloads (3.7-10.2) and skill mix (54-82% nurses). More than one in five nurses (11-56%) were dissatisfied with their jobs in most countries, and dissatisfaction was pronounced with respect to wages, educational opportunities and opportunities for advancement. Sizable percentages (19-49%) of nurses intended to leave their jobs, though the percentage that thought it would be easy to find another job varied greatly across countries (16-77%). Nurse concerns with workforce management and adequate resources were widespread. While most nurses did not give their hospitals poor grades on patient safety, many doubted that safety was a management priority. Nurses reported that important nursing tasks were often left undone because of lack of time, and indicated that adverse events were not uncommon.Nurse shortages can be expected when national economies improve unless hospital work environments improve. Wide variation in nurse staffing and skill mix suggests a lack of evidence-based decision making. Additional research is warranted on the impact of these variations in nurse resources on patient outcomes.

Background Nurses' work environments are associated with burnout experiences among nurses. The RN4CAST project provides data on these constructs within a four-level structure (nurse, nursing unit, hospital, and country), implying more complicated multilevel analysis strategies than have been used in previous efforts studying this relationship. Objectives First, to explore and investigate the effect of the nursing unit, hospital, and country level variability on the relationship between dimensions of nurses' work environment and dimensions of burnout. Second, to explore the significance of the nursing unit, hospital, and country level variability among the burnout dimensions. Design Data from the RN4CAST project were available from a cross-sectional survey among 23,446 nurses in 2087 nursing units in 352 hospitals in 11 countries. Methods Nurse-reported information on their work environment (managerial support for nursing, doctor–nurse collegial relations, and promotion of care quality) and burnout experiences (emotional exhaustion, depersonalization and personal accomplishment) were available. We specified ecological measures of the nurse work environment dimensions at the three organizational levels and combined these with individual-level outcomes within a series of multilevel statistical models. The final model was a multivariate multilevel probit model in which we modeled the work environment and burnout dimensions jointly. Results Doctor–nurse collegial relations affected all burnout dimensions, but at the unit level only. For the dimension of promotion of care quality, the effect of the ecological exposure on burnout was pronounced at both the nursing unit and the hospital level for all three burnout dimensions. Findings for the dimensions of managerial support for nursing were ambiguous. Conclusion Nurse work environment dynamics are related to nurses' burnout experiences at both the nursing unit and the hospital level. This implies that both hospital-wide and unit-specific interventions should be considered to achieve excellent work environments. The correlation structure among the three burnout outcomes varies across countries, but is stable between hospitals within countries and between nursing units within hospitals.

Objective: Cost containment is exerting pressures on the hospital nurse workforce that may conflict with quality and safety improvement. Europe is an ideal laboratory for determining how to realign organisational behaviors to achieve good patient and workforce outcomes in a context of finite resources. Design: Cross-sectional surveys of patients and nurses.Setting: Nurses were surveyed in 488 general acute care hospitals in 12 European countries and 617 general acute care hospitals in the United States. Patients were surveyed in a subset of 210 of the European hospitals and 430 of the United States hospitals.Participants: 33,659 nurses and 11,318 patients in Europe and 27,509 nurses and over 120,000 patients in the United States.Measurements: Hospital staffing, nurse work environments, burnout, dissatisfaction, intentions to leave, patient safety, quality of care, patient satisfaction overall and with nursing care and willingness to recommend their hospitals.Results: The percentage of nurses reporting poor or fair quality of patient care varied substantially by country from 11% (Ireland) to 47% (Greece) as did the percentage that gave their hospital a poor or failing safety grade (4% in Switzerland to 18% in Poland). High nurse burnout ranged from 10% (Netherlands) to 78% (Greece), job dissatisfaction from 11% (Netherlands) to 56% (Greece), and intent to leave from 14% (United States) to 49% (Finland and Greece). Percent of patients rating their hospitals highly varied considerably across countries from 35% (Spain) to 61% (Finland and Ireland), as did the percentage of patients that were willing to recommend their hospital (53% in Greece to 78% in Switzerland). Better work environments and lower patient-to-nurse ratios were associated with higher care quality and higher patient satisfaction. After adjusting for hospital and nurse characteristics, nurses in European hospitals with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval, 0.51 to 0.61) and to give their hospitals poor or failing grades on patient safety (adjusted odds ratio 0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds on nurses reporting poor or fair quality car (adjusted odds ratios 1.11, 1.07 to 1.15) and poor or failing safety grades e (adjusted odds ratio 1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (adjusted odds ratio 1.16, 1.03 to 1.32) and to recommend their hospital (adjusted odds ratio 1.41, 1.22 to 1.62), while patients in hospitals with higher patient-to-nurse ratios were less likely to rate their hospital highly (adjusted odds ratio 0.94, 0.91 to 0.97) or recommend their hospital (adjusted odds ratio 0.95, 0.91 to 0.98). Findings were similar in the United States. Nurses and patients agreed on which hospitals provided good care and could be recommended.Conclusions: Hospital care quality deficits were common in all countries. Improving hospital work environments may be a relatively low cost lever to produce safer and higher quality hospital care and higher patient satisfaction.

The aim of the present study was to evaluate the association between illness perceptions and the ability to cope with physical and mental health problems in a large cohort of systemic sclerosis (SSc) patients.This was a cross-sectional study in 217 systemic sclerosis patients from the Belgian Systemic Sclerosis Cohort. Illness perception and coping were measured by the Revised Illness Perception Questionnaire and a coping questionnaire--the Coping Orientation of Problem Experience inventory (COPE). Physical and mental health-related quality of life was measured by the 36-item short-form health survey (SF-36), as were disease activity and several severity parameters. The relationship between illness perceptions and the ability to cope with physical/mental health problems was examined using multiple linear regression analysis.According to LeRoy's classification, 49 patients had limited SSc (lSSc), 129 had limited cutaneous SSc (lcSSc) and 39 had diffuse cutaneous SSc (dcSSc). Median disease duration was five years and the modified Rodnan skin score was 4. Good physical health was significantly associated with the lcSSc subtype and low disease activity (p 0.01 and p 0.05, respectively). The perception of 'serious consequences' and strong 'illness identity' correlated with poor physical health (p 0.001). Good mental health was associated with low illness identity scores and low 'emotional response' scores (p 0.001). Coping variables were less significantly correlated with physical and mental health compared with the illness perception items.Illness representations contribute more than classical disease characteristics to physical and mental health.

Background With poor prognosis and disabling symptomatology high-grade gliomas affect not only the patient but also the family. Purpose The aim of this systematic review is to explore the experiences and needs of patients with a high-grade glioma and their family caregivers. Method Based on literature search in six databases, sixteen qualitative studies, published between 2000 and 2010 and with mixed methodological quality, were included. Results For both patients and their caregivers the diagnosis is marked by shock and recognition of death. For patients, coping with restriction seems to be most difficult to deal with. Especially loss of autonomy is hard. For caregivers, neurocognitive symptoms and personality changes irreversibly change the relationship with the patient leading to caregivers expressing a sense of total responsibility. The experience of being a caregiver is described by positive as well as negative feelings. Both patients and caregivers describe the need for hope, support and information. Conclusion The review provides some relevant insight in the experiences and needs of patients with a high-grade glioma and their caregivers. The methodological limitations of the included studies, however, urge for more research to refine our understanding of patients’ and caregivers’ experiences and needs to better tune care to their needs.