Structure et fonctionnement des services québécois de néonatologie et leurs relations avec la qualité des soins et des indicateurs de santé au travail chez les infirmières

Introduction. The increasing demand for the services for premature and at-risk infants, combined with a shortage of nurses specialized in neonatal intensive care nursing and recent changes in legislation defining professional nursing in Quebec, are forcing managers and policymakers to revisit the organization of nursing services on neonatal intensive care units (NICUs). Yet, few studies have examined the effect of the organization of neonatal services on the quality of patient care and on nurses' work and health outcomes.

Objective. To describe the structure and the functioning of Quebec's network of neonatal units in order to understand their influences on nurses' work and health outcomes as well as on nurses' perceptions of the quality of patient care in NICUs.

Design. A mixed-methods design comprising both a multiple-case study (qualitative portion) and a prospective analysis of survey-based data (quantitative portion).

Population. Nursing staff, physicians, health care professionals, clinical managers, and NICU patients' parents recruited from 2 NICUs in Québec (qualitative portion), and 650 nurses from 7 NICUs in Quebec (quantitative portion).

Data sources. The qualitative fieldwork included 46 interviews and 500 hours of participant observation guided by structured tools. The quantitative data analyzed were gathered using a survey that included the Revised Nursing Work Index (Aiken & Patrician, 2000) (NWI-R) –a measure of perceptions of the availability of organizational supports for professional nursing practice, a newly-developed tool examining rationing of nursing work processes, nurses' job satisfaction, burnout and perceived quality of patient care. These data sources were supplemented with information from Quebec Ministry of Health administrative databases.

Analyses. Qualitative data were analysed using content analysis and grounded theory strategies. Multiple regression models, predicting the rationing of nursing services, nurse job satisfaction, and burnout and nurses' perceptions about the quality of patient care were tested using professional practice environment characteristics measured using the NWI-R as the major independent variables controlling for nurses' demographic characteristics and adjusting for the clustering of nurses within hospitals.

Main study findings. Higher ratings of the quality of the professional work environment were associated with decreased reporting of omissions (rationing) of specific types of nursing care, higher levels of nurses' health at work and more favourable nurse perceptions about the quality of patient care. The qualitative fieldwork supported many of these connections but found that the benefits of professional work environments are contingent on contextual elements that emerge from the complex action system that underpins Quebec's network of neonatal units relating to both demand for services and resources for providing care.

Conclusion. The practice of nurses in Quebec NICUs appears to be influenced by the same work environment elements that predict job and patient outcomes in prior research in other clinical settings and in other provinces and countries. Managers and executives seeking to ensure consistent quality of nursing care and reduce negative job outcomes associated with turnover in NICUs should develop professional work environments within their organizations. However, consideration of, and potentially political action around, the various forces constraining resources in Quebec's network of neonatal units will also be necessary to ensure high-quality care, particularly in the future.

Keywords. Organization of nursing services, neonatology, complex action system, professional practice, nurses' health at work, quality of patient care, qualitative research methods, survey.