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. Author manuscript; available in PMC: 2021 Mar 29.
Published in final edited form as: Int Nurs Rev. 2015 Apr 28;62(3):412–420. doi: 10.1111/inr.12191

Research lessons from implementing a national nursing workforce study

T Brzostek 1, P Brzyski 2, M Kózka 3, A Squires 4, L Przewoźniak 5, M Cisek 6, K Gajda 7, T Gabryś 8, M Ogarek 9
PMCID: PMC8006064  NIHMSID: NIHMS1680008  PMID: 25918981

Abstract

Background:

National nursing workforce studies are important for evidence-based policymaking to improve nursing human resources globally. Survey instrument translation and contextual adaptation along with level of experience of the research team are key factors that will influence study implementation and results in countries new to health workforce studies.

Aim:

This study’s aim was to describe the pre-data collection instrument adaptation challenges when designing the first national nursing workforce study in Poland while participating in the Nurse Forecasting: Human Resources Planning in Nursing project.

Methods:

A descriptive analysis of the pre-data collection phase of the study. Instrument adaptation was conducted through a two-phase content validity indexing process and pilot testing from 2009 to September 2010 in preparation for primary study implementation in December 2010. Means of both content validation phases were compared with pilot study results to assess for significant patterns in the data.

Results:

The initial review demonstrated that the instrument had poor level of cross-cultural relevance and multiple translation issues. After revising the translation and re-evaluating using the same process, instrument scores improved significantly. Pilot study results showed floor and ceiling effects on relevance score correlations in each phase of the study.

Limitations:

The cross-cultural adaptation process was developed specifically for this study and is, therefore, new. It may require additional replication to further enhance the method.

Conclusions:

The approach used by the Polish team helped identify potential problems early in the study. The critical step improved the rigour of the results and improved comparability for between countries analyses, conserving both money and resources. This approach is advised for cross-cultural adaptation of instruments to be used in national nursing workforce studies.

Implications for nursing and health policy:

Countries seeking to conduct national nursing workforce surveys to improve nursing human resources policies may find the insights provided by this paper useful to guide national level nursing workforce study implementation.

Keywords: Content Validity Indexing, Cross-Cultural Instrument Validation, Health Workforce, Human Resources for Health, Nurses, Nursing, Poland, Survey Research

Introduction

Nursing workforce research grows annually on a global scale. The development of nursing research in countries with no previous history and the need to address nursing workforce issues means many other countries have now begun to study the same phenomenon using the previously developed, internationally standardized methods.

The purpose of this study is to describe how the Polish research team from the Nurse Forecasting: Human Resources Planning in Nursing (RN4CAST) study – a 12-country comparative nursing workforce study in Europe funded by the European Union (EU, http://www.rn4cast.eu/en/index.php) – managed the cross-cultural research design and instrument adaptation process. The Polish case was unique in the RN4CAST study for two reasons: (a) nursing workforce research is just beginning in Poland and (b) this kind of workforce study was the first one ever conducted in the country. The ‘newness’ of this research in the Polish context presented multiple challenges for the research team that may provide useful lessons for researchers in other countries just beginning to develop their capacity for conducting nursing workforce studies, particularly when utilizing the instruments developed in the another language and cultural context than their own.

Background

National or regional health workforce studies provide valuable data and perspectives about working conditions, job satisfaction, forecasting issues and the impact of these findings on patient outcomes (Aiken et al. 2013; Ausserhofer et al. 2014; Bell et al. 2013; El-Jardali et al. 2009; Hinno et al. 2011; Losa Iglesias et al. 2010; Schubert et al. 2012; Van den Heede et al. 2009; You et al. 2013). With nursing shortages in nearly every country in the world, studies such as these help document the conditions and impacts on patient outcomes that shortages have and become critical tools for health workforce policymaking that is specific to nursing personnel. Health workforce research in many Western countries, predominantly English speaking ones, has laid the foundation for regional and national workforce studies. Replicating this work in countries ‘new’ to health workforce research is important to show where similarities and differences exist.

Poland is a country where nursing research in general is ‘new’ compared with its European counterparts and a place where the need for a national nursing workforce study was great because of multiple educational and health system reforms that have taken place during the last 20 years. These have included: (1) nursing’s legal recognition as an autonomous profession, (2) the establishment of occupational self-governance, and (3) educational reforms to align with the EU standards to meet the requirements of the EU Directive2005/36 EC (Ministry of Health 2000; Ministry of Health 2002) and conform to the Bologna structure of bachelor degree (first-cycle) and master (second-cycle) degree. These reforms resulted in the number of schools reducing from 129 to 19 programmes in public universities and 74 higher schools of vocational education (Ministry of Health 2014). The drop in the number of schools also paralleled a decreased interest among young people pursuing nursing as career option, with the number of nurse graduates falling from 14 000 in 1995 to 2500 in 2000 (Ministry of Health 2002; Kózka 2004). In subsequent years (2001–2012), the number of trained nurses increased by 30 000 but this still does not meet the needs of the national healthcare system. At present, the nurse employment rate per 1000 inhabitants in Poland in 2008 was 4.9, the lowest in Europe (Kózka et al. 2011).

Additional nursing labour market trends that drove the need for a national nursing workforce study include looming mass retirements and shorter bedside nursing careers. First, the Ministry of Health established minimum hospital nurse staffing through national regulatory measures (Ministry of Health 2012). These minimum requirements incorporate the estimated direct and non-direct nursing time, as well as the specific features of the unit organization such as category of patients’ care which takes into account the patient’s condition and degree of independence. Several contextual factors related to the nursing labour market complicate the implementation of this policy. In Poland, by the year 2020, around 80 000 nurses will retire and only 20 000 will be available to replace them (Naczelna Rada Pielęgniarek i Położnych 2010). Furthermore, a significant percentage of the graduates do not work for a long time at the bedside, often less than 10 years. Reasons for them leaving their jobs are not well understood yet in the Polish context.

Additionally, limited professional and role-based autonomy in everyday nursing practice, the weak position of nursing management in healthcare organizations, a relatively poor work environment and low remuneration of nurses further contribute to the complexity of the Polish situation (Glińska & Lewandowska 2007; Kiczka 2010; Kosińska & Pilarz 2005; Kunecka 2010; Kunecka et al. 2007; Kuriata et al. 2011; Radkiewicz et al. 2004; Zielińska–Więczkowska & Buśka 2010). Even though at the operational level the minimum standards for nurse staffing are defined by the hospital manager (director/chief executive officer) based on available resources, unit type, the scope of nursing activities and the principles regulating working conditions within the unit, the current situation is so dissatisfying for nurses that in 2009, the Ministry of Health appointed an expert panel to prepare new legislation for nurses to improve employment opportunities and working conditions (Ministry of Health 2009). While findings from the Polish RN4CAST study are currently helping to inform this committee’s work, few changes have been seen to date. Thus, despite what the international evidence has demonstrated about the relationships between staffing, patient outcomes and nurses’ care (Klopper et al. 2012; McHugh et al. 2013; Rogers et al. 2004; Stimpfel et al. 2012; You et al. 2013), overall domestic nursing workforce policies in Poland do not reflect the research findings nor account for the domestic nursing labour market realities.

The combination of the aforementioned factors meant that in 2009, Poland was ripe for a national nursing workforce study that would create the evidence needed to make better national and organizational policy for nurses. As the study would be the first of its kind in the country, the team anticipated many implementation challenges. Some of these challenges would be expected while conducting survey research. Others were unique to the Polish context where nursing research is new and therefore, research capacity building also had to accompany study implementation. This paper specifically focuses on the cross-cultural survey instrument adaptation and testing process employed by the team prior to the main study’s national data collection that occurred in late 2010 and early 2011. Nurses from countries with similar labour market issues, where health services research is new or where nurse-led research is also new, may find the lessons from the Polish case valuable when planning a similar study.

Aims

We seek to describe the process the Polish national research team took to address key challenges they faced when designing and implementing the first national nursing workforce study in Poland while participating in the EU RN4CAST project between 2009 and 2011. Thus, the primary emphasis of this paper is on the cross-cultural instrument adaptation process. It involved a two-phase pilot study prior to the primary data collection that occurred in late 2010 and early 2011. Data from the primary parent study continues to undergo analysis at the time of publication. We emphasize the lessons learned from the instrument adaptation process because it is a common and significant methodological threat to the rigour of any cross-sectional study where an instrument is translated from a source language to a target language.

Methods

Too few studies place adequate emphasis on cross-cultural adaptation of survey instruments in health workforce research studies prior to data collection (Erkut 2010; Maneesriwongul & Dixon 2004). Thus, the methods section of this paper emphasizes the early stage of the study’s implementation process, which proved critical for the success of the overall study. The pilot testing process involved: (1) content validation of the translated survey instrument items by a panel of experts, (2) pilot testing of the instrument, (3) additional editing of the instrument after testing, and (4) repeat content validation.

We begin with how the team managed the cross-cultural validation and language translation of the RN4CAST study instrument for use in the Polish context. The RN4CAST study instrument consists of four parts and 110 items: section A contains the Practice Environment Scale of the Nursing Work Index (PES-NWI), the Maslach Burnout Inventory for Human Services Survey (MBI-HSS) and job satisfaction questions; section B contains standardized and validated job satisfaction questions; section C is comprised of patient safety questions and the final section, D, contains demographic questions. Multiple studies have tested, validated and conducted secondary analyses on the combination of instruments used in the RN4CAST study (see works by Aiken et al.). To cross-culturally evaluate the instrument, the process included a systematic, blended cross-cultural and language translation approach, along with a pilot test of the survey instrument. Ethics committee approval was obtained from an American and Polish university to conduct the study.

The systematic translation approach used by the Polish team was implemented by all participating countries in the RN4CAST study. It is described in detail in Squires et al. (2013).

In summary, it began with an expert panel review by experienced health services researchers (Sermeus et al. 2011) and was followed by an assessment that produced a translation guide to help with determining conceptually, semantically, and technically equivalent words and phrases. Forward and back translations by two separate translators with the highest qualifications available within the country’s resources took care of the technical aspects of translation. Finally, an expert panel review using content validity indexing (CVI) techniques evaluated the English and translated versions.

As utilized for this study, the CVI process produces data that evaluates the relevance of the survey question to nursing in the country and then checks the conceptual, contextual, content, semantic and technical equivalence of an existing survey instrument (Squires et al. 2013). The expert panel scores the relevance of each survey item on a 1 to 4 rating scale, with 1 = not relevant and 4 = highly relevant. Using the chance agreement correction formula provided by Polit et al. (2007), item level (I-CVI) and scale level (S-CVI) scores are produced and generates a comparison modified kappa score (k scores evaluated using the scale recommended by Ciccheti & Sparrow 1981). Researchers can repeat the process if problems with cross-cultural equivalence or language translation emerge. That allows them to compare initial and revised scores to see if the problems were corrected in the second round.

Pilot testing a survey instrument is a further step to evaluate its cross-cultural relevance. The RN4CAST survey instrument was pilot-tested in the European context prior to implementation across participating nations (Bruyneel et al. 2009). Additional country-specific pilot testing remained an option for all countries, but one that the Polish team undertook in order to ensure additional rigour of the cross-cultural equivalence of the instrument. It was also an important step to complete because of the need to build nursing research capacity and increase the likelihood that the results would be perceived as reliable and valid because this kind of study had no precedence in the country.

Pilot study sample participants and data collection

For the pilot study, data were collected over a 2-month period of early 2010 at one hospital in a large university city. All nurses working in surgical and medical wards of this hospital, according to the RN4CAST protocol (Sermeus et al. 2011), were invited to participate. Table 1 illustrates the sample demographics. Altogether, 113 nurses were employed on these wards [64 on the medical and 49 on the surgical wards, mean age 37.7 (SD 8.6)]. One hundred ten paper questionnaires were distributed (63 on the medical and 47 on the surgical wards). Ninety-seven questionnaires were returned (55 on the medical and 42 on the surgical wards), which gives altogether an 88.2% response rate (87% on the medical and 89% on the surgical wards). No negative information concerning unclear phrasing or irrelevant content of the questions was received from the nurses participating in the pilot study.

Table 1.

Pilot study participant demographics

Variable Category %
Age of obtaining nurse diploma (years) ≤20 39
21–22 44
23+ 17
University bachelor degree yes 33
Duration of professional work as a nurse ≤14 49
15+ 51
Full-time employment yes 86
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Data analysis

I-CVI scores were calculated for each survey item while S-CVI scores were calculated for each section and the entire survey for both the pre-pilot study CVI rating and the post-pilot study one. Descriptive statistics highlighted missing data patterns from the pilot study which were used to analyse floor/ceiling effects. It was important to analyse floor/ceiling effect sizes for several reasons. During cross-cultural instrument adaptation, the ideal situation concerning validation of a questionnaire is to compare results of the survey with distributions of measured variables known from other studies or even no scientific sources (such as national registers, and censuses). In this case, because no such resources were available to compare with previously analysed survey data from the Polish context, the researchers made an assumption that the measured variables had normal distributions in the population from which the study sample was drawn. Under such an assumption, ratings with average values of measured variables predominate in the population and one should not observe too many scores with extreme values in the measured sample. Therefore, we assumed that variables that tend to concentrate a higher number of answers in the extremes categories may be of lower reliability than others. Simple t-tests were then used to compare CVI ratings. We then compared S-CVI scores using the Wilcoxon signed rank test for dependent samples between survey sections to determine if there was a ratings bias of problematic items in one section more than another. This step would help determine if one section of the survey was skewing the overall CVI rating results.

Results

We present the results as the pre-data collection portion of the study was implemented. First, we review the results of the first round of expert rater analyses using the CVI approach. Then we compare both the pre- and post-pilot study CVI results to the initial pilot study responses from the nursing staff.

First CVI rating

All scores reported here represent S-CVI scores corrected for chance agreement through a modified kappa calculation, using the formula suggested by Polit et al. (2007). The S-CVI score of the entire RN4CAST questionnaire translated to Polish reached 0.61 (SD 0.16, minimum 0.30, maximum 1.00). One-third (38.3%) of items obtained satisfactory S-CVI value of 0.7 or greater. The S-CVI values varied across the questionnaire, with the lowest for part B and the highest for part D. Scores for the PES-NWI reached mean value of 0.60 – close to the mean value for whole questionnaire, whereas the values for MBI items were higher 0.68. Table 2 summarizes the CVI scores. The team’s next step of conducting a pilot study would confirm how problematic the variability and low scoring items might be for a larger nursing workforce survey.

Table 2.

Section comparison of content validity indexing (CVI) values (using modified kappa score) for the first (1. CVI) and the second (2. CVI) rating of the survey instrument

Number of items Mean SD Minimum Maximum
Part A global 1. CVI 70 0.62 0.13 0.40 0.90
2. CVI 70 0.81 0.11 0.44 1.00
 Practice Environment Scale 1. CVI 32 0.60 0.10 0.40 0.80
2. CVI 32 0.76 0.12 0.44 0.89
 A4 1. CVI   9 0.59 0.13 0.40 0.80
2. CVI   9 0.75 0.09 0.56 0.89
 A2–A8 except A4 1. CVI   7 0.61 0.11 0.50 0.80
2. CVI   7 0.78 0.00 0.78 0.78
 Maslach Burnout Inventory 1. CVI 22 0.68 0.15 0.40 0.90
2. CVI 22 0.90 0.08 0.78 1.00
Part B global 1. CVI 24 0.51 0.17 0.30 0.90
2. CVI 24 0.76 0.11 0.56 1.00
Part C global 1. CVI 36 0.56 0.15 0.30 1.00
2. CVI 36 0.80 0.12 0.56 1.00
Part D global 1. CVI 11 0.87 0.08 0.70 1.00
2. CVI 11 0.84 0.08 0.67 0.89
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Note: Modified kappa conversion of CVI scores use the following scale from Ciccheti & Sparrow (1981): >0.74 = excellent; 0.60–0.73 = good; 0.51–0.59 = fair; <0.50 = poor.

Pre-pilot study CVI scores compared with pilot study results

We compared the I-CVI scores to the pilot study results by looking at (1) the percentage of missing data by item compared with the item’s CVI score and (2) I-CVI values and floor-ceiling effect size. Initially, we did not observe significant relationship between value of I-CVI for particular item and percentage of missing data obtained for that item during pilot study (r = −0.07). We did, however, observe a statistically significant relationship between the values of I-CVI coefficients and the existence of a floor or ceiling effect, expressed as the percentage of responses located in the lowest or the highest category of particular variable, respectively. The correlation coefficient for the I-CVI value of the particular item and size of the floor effect is −0.53. The value for the ceiling effect is 0.33. This indicates that as I-CVI value increases, the percentage of observations located in the lowest categories of the items decreases, consequently decreasing the right skewness of the distribution. However, positive correlation between I-CVI and ceiling effect size suggests that percentage of observations located in the highest categories of the items increases slightly with an increase in the I-CVI of the items.

Comparing CVI ratings

We compared the item level CVI means between the first and second rating process. The mean value of the item level CVI coefficient values for the first translation and for the second corrected version showed an increase from 0.62 (SD 0.16) to 0.80 (SD 0.11, minimum 0.44, maximum 1.00). Three-fourths (79.4%) of the items reached CVI value at least 0.7 or higher compared with only 38% during the initial evaluation. Overall, this represents a statistically significant change (P = 0.000).

Further analysis of I-CVI changes with respect to the particular parts of the questionnaire showed several trends. First, the mean CVI increased significantly (P = 0.000) for parts A, B and C and the overall instrument. Furthermore, parts A and B had statistically significant differences from each other on the first CVI rating (P = .045), but this disappeared after the translation corrections (P = 0.32). Unsurprisingly, I-CVI values for part D (Demographics; initially 0.87) remained statistically unchanged. Table 2 illustrates the changes in the CVI scores.

Finally, the correlation between pilot study and the second rating showed that the percentage of missing data and ceiling effect size was no longer significantly correlated with the second round of ratings. The correlation between floor effect size from the pilot study and the second CVI ratings decreased to −0.31.

Discussion

In terms of national nursing workforce study implementation, the Polish case offers many valuable insights for countries across all income strata. Before the RN4CAST study, no national nursing workforce analysis using internationally accepted instruments that were developed in English were performed for Poland. Previous studies in Poland did not have rigorous reliability or validity assessments and tended to focus on single patient care units. Using an international standardized questionnaire, such as the one in the RN4CAST study, allowed the team to collect national data that would also be comparable with other EU countries. Achieving transcultural equivalence of the questionnaire was a crucial point for further analysis.

It is important to note that the root of the statistically significant differences in the CVI ratings between the sections came from the translations of the survey items. As stated earlier, section A of the instrument contained the well-known PES-NWI-R and the MBI-HSS. Both of these instruments have multiple items that can present major conceptual and semantic equivalence problems for translation (Squires et al. 2013, 2014). Section B focuses on patient safety and quality of care issues. The commonality between the two sections is that they have very US-specific English language and health system colloquialisms that can present problems with translations. The CVI scores in the first rating process revealed these problems with translation and the second round showed that they had resolved. The pilot study results reinforced those findings. Methodologically, therefore, we would expect that a reliable and valid instrument would present no statistically significant differences between sections that had undergone a cross-cultural evaluation process rooted in the CVI approach.

Among the aforementioned recommendations that have emerged from these findings, experts have identified a common pattern that researchers should avoid when replicating similar studies. Often times, when researchers adapt instruments for national nursing workforce surveys to a new setting and context, the cross-cultural and contextual evaluation steps are often overlooked as researchers settle for simple forward and backward translation as their adaptation approach (Erkut 2010; Maneesriwongul & Dixon 2004; Weeks et al. 2007). An important lesson from the Polish case in the RN4CAST study was that while the Polish scores qualified as ‘good’ for the modified kappa value, they were very different from scores from other countries which all had achieved ‘excellent’ ratings of 0.74 or higher (see Squires et al. 2013 for individual country results from the study). Variability between the scores was also considerably wider for the Polish translation when compared with other countries. The results from the team’s efforts to conduct a rigorous pre-data collection evaluation of the survey instrument demonstrated the value and importance of this step in the research process and highlight its importance as a step for a national nursing workforce survey. The initial CVI process highlighted where errors in translation occurred that may have affected survey responses in the pilot data. Comparing the CVI results with the pilot test responses confirmed where issues in the instrument appeared and would have affected the broader survey results had this step not occurred. Finally, the results demonstrated that the changes made to the instrument improved its reliability when measuring work environments, burnout and nursing-sensitive patient safety measures.

Furthermore, because the CVI approach can quantify semantic, technical, conceptual, contextual and criterion-related issues during cross-cultural adaptation process, the researcher has the ability to compare scores with the pilot study results. That analytic step helps to increase rigour and improve the reliability of the adapted instrument. The final comparison between the first and second round of CVI scores and the statistically significant changes in the scores also confirms the impact these steps can have when adapting instruments for use in other countries. Previous studies have not been able to quantify the cross-cultural evaluation component and this study offers an option for researchers to undertake that step.

As funds for national nursing workforce studies are often limited even in high-income countries, the CVI process can also be conducted at a relatively low cost. The entire process can be carried out on paper or using simple spreadsheet software. Notably, the Polish part of the study had the least amount of domestic funding of any country involved. The CVI process ensured, at minimal cost, that the cross-cultural adaptation of the instrument could happen and not detract significantly from the funds needed for the larger study. More importantly, because the cross-cultural adaptation effort occurred prior to data collection, it saved the team considerable expense in terms of time and effort because they did not have to compensate for high rates of missing data or account for a large number of outlier responses among participants.

Implications for research

Research teams in countries where national nursing workforce surveys are new need to consider that tools and instruments developed in English and in a specific country do require a cross-cultural adaptation process to ensure the reliability and validity of the instrument in a new context. This is especially true for low- and middle-income countries where concepts measured by survey instruments may differ significantly from their original intent. A classic example is what it means to have enough supplies. A qualitative study by Squires & Juárez (2012) showed that nurses described issues with supply management and lacking supplies for several days or up to a week, sometimes more. A nurse in most European countries might run out of key supplies during the shift. The RN4CAST instrument simply asks about nurses’ perceptions of having enough supplies without considering contextual factors. Capturing the conceptual difference between contexts is an important part of the cross-cultural adaptation process when implementing a national nursing workforce survey.

For future research studies that may wish to replicate this approach, the cross-national comparison conducted by Squires et al. (2013) suggests that a minimum of seven raters participate in the CVI process (as with five raters all must agree on every item, which is nearly impossible to achieve) and that a maximum of ten would suffice. Countries should be able to recruit seven to ten raters to participate in the CVI process and recommendations by Grant & Davis (1997) provide useful guidelines for overall rater selection. It may be challenging, however, to find bilingual nurses (usually English and the country’s language) in many cases. When researchers encounter this problem, blending raters with nurses and non-nurses can be an acceptable strategy. Researchers could also have a group of bilingual expert raters conduct one round of CVI analyses and then have expert nursing raters complete a second round. Scores between the groups can then be compared with simple t-tests.

Policy implications

As the RN4CAST study has demonstrated, national nursing workforce surveys produce highly valuable data that can enhance the quality of nursing human resources policymaking. As we strive for evidence-based practice in the clinical setting, nursing human resources policies also need to move towards a stronger evidence-based foundation and national nursing workforce studies using internationally comparable tools are a solid step in that direction. A well-designed study that carefully manages the pre-data collection instrument adaptation process is an important part of these kinds of studies and resources should be budgeted accordingly.

Limitations

As with any study, the implementation approach to the pre-data collection portion of the study had some limitations. First, the systematic translation method was developed specifically for the RN4CAST study and tested across the 12 countries involved. Further testing and replication of the approach may be required. A second limitation was that not all of the raters from the first round of the CVI-based instrument evaluation process were the same. While diversity of views could enhance the rigour of the analysis, not having exactly the same group reviewing the items could have influenced the scores. Finally, it was also difficult to recruit raters with adequate English language skills who could successfully complete the process and this added time to the overall process. This is another implementation challenge that some countries may face and may need to consider when adapting a survey instrument to their country.

Conclusion

As countries begin to focus more on the nursing workforce and its role in health services delivery, national nursing workforce surveys will become increasingly important to shape national nursing workforce policy. They can offer valuable insights for where scarce resources can be directed to have the largest operational impact. Even though the literature shows that there are similar issues with the nursing workforce across countries, each context is unique and will likely require individual country results. Using standardized and validated instruments strengthen the validity of results from national nursing workforce surveys and allow international comparisons to occur, thereby deepening our understanding of nursing workforce dynamics. Yet, these results will only have the strength they need if rigorous, pre-data collection cross-cultural adaptation of the instrument occurs. It is a key part to successful study implementation.

Acknowledgements

The authors would like to thank Melissa Martelly, MS, RN, for assistance with manuscript preparation and submission.

Funding statement

This study was conducted through the generous funding of a grant agreement no. HEALTH-F2-2009-223468 project ‘Nurse Forecasting: Human Resources Planning in Nursing’ (RN4CAST), the European Union’s Seventh Framework Programme FP7/2007-2013 under grant agreement n° 223468 (W. Sermeus, PI), the National Institute of Nursing Research, National Institutes of Health (P30NR05043 L. Aiken) and a New York University College of Nursing Faculty Research Fund.

Footnotes

Conflict of interest statement

All authors report no conflicts of interest.

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