The Dutch healthcare system does not require nurse anaesthetists to have nursing backgrounds. The educational preparation for nurse anaesthetists in the Netherlands consists of a three-year program at the Higher Professional Education Bachelor’s level. The program is accredited by the National College of Hospital Training, and results in a nationally certified “nurse anaesthetist” diploma from the Dutch Society of Hospitals. The admission requirements for the nurse anaesthetist program are either a senior high school diploma with a specialization in physics and health, or nursing degrees level 4 or 5 (the latter results in a bachelor degree)1*. Therefore, it is possible to go directly from a senior high school to a three-year bachelor program and become a nationally certified nurse anaesthetist.

The curriculum of the program is the same for students with and without nursing backgrounds. The program includes anaesthesia, physics, anatomy, pharmacology, medical techniques, medical law and ethics as well as nursing skills and competences. Students with nursing backgrounds receive exemptions from the courses in nursing skills and competences. At the end of the three years, the Dutch nurse anaesthetist professional who has completed this course of study can be compared to a registered nurse anaesthetist (RNA) at the bachelor’s level in other countries [1].

Dutch nurse anaesthetists work in anaesthesia departments under both the direct and indirect supervision of anaesthesiologists. They never perform the induction of anaesthesia on their own, but they are the ones who stay with the patient for the entire procedure, although an anaesthesiologist is always present in the immediate vicinity of the operating theatre, or in direct (mobile) phone contact and is readily available to help if necessary. However, it is the nurse anaesthetist who continuously monitors the patient and is responsible for the patient’s anaesthesia, analgesia and safety throughout the operative period.

The debate is whether nurse anaesthetists who first were trained as nurses and worked as nurses on wards before starting their anaesthesia training are better suited for and “fit for the job” than those without this nurse training and working experience. “Fit for the job” is defined as a concurrence of perceptions of work environment, personal competence, wellbeing and organisational standards. A person-environment (PE) fit is established when characteristics of the nurse anaesthetist and work environment are compatible [2]. The PE fit influences job satisfaction, organisational commitment, turnover intention, well-being and performance [3, 4]. An imbalance between the nurse anaesthetist and his/her environment (PE fit) can result in sickness absenteeism, burnout, psychosomatic symptoms, and lower job satisfaction [3, 5, 6].

It is a common belief that nurse anaesthetists with nursing training and work experience perform better than nurse anaesthetists without nursing backgrounds. We hypothesized that nurse anaesthetists with nursing backgrounds have more positive job perceptions compared to their colleagues without. In order to test this hypothesis, we performed an explorative survey, measuring the work context factors, job satisfaction, psychosomatic symptoms, burnout, work climate and turnover intention of Dutch nurse anaesthetists with and without nursing backgrounds.

METHODS

All 2.000 Dutch nurse anaesthetists, working in both hospitals and private clinics, were approached to fill out an on-line multiple choice questionnaire consisting of demographic, psychosomatic and work context items. The study was launched at the annual Dutch national congress of nurse anaesthetists; each participant of the conference received an invitation to fill out the questionnaire. To reach the nurse anaesthetists who did not attend the conference, a personal letter was sent to every member of the Dutch Society of Nurse Anaesthetists (Nederlandse Vereniging van Anesthesiemedewerkers). Moreover, a letter was sent to the directors of private clinics and employment agencies, asking their nurse anaesthetists to participate in the study. The on-line questionnaire was closed three months later. The study was approved by the Medical Ethical Committee of the Catharina Hospital Eindhoven, the Netherlands. The demographic characteristics collected in the survey included age, gender, nursing credentials, percentage of employment (part-time or fulltime), working irregular shifts (e.g. night shifts), number of training days per 5 years, and number of operating rooms.

The multiple mechanisms of PE fit mean that multiple conceptualisations of it are likely to produce stronger evidence than a single conceptualisation [7]. The subjective fit was assessed by indirectly comparing the person and environment information from the same participant. The following multi-conceptual work variables were tested: work context factors, job satisfaction, psychosomatic symptoms, burnout, absenteeism, general health, work climate, and turnover intention.

The characteristic aspects of individual work perceptions of nurse anaesthetists were measured using the TOMO (Toetsingslijst Mens & Organisatie; literally translation: checklist people & organisation), which is based on work motivation models introduced by Maslow, Herzberg, Hackman & Oldham and Karasek [8]. Most studies involving work context use a questionnaire consisting of one or more of the following factors: autonomy, social relations, competence and environmental conditions [5, 8, 9]. However, none of these questionnaires examines all four factors. This problem is addressed by the use of the TOMO, developed by Van Orden et al. [8], who integrated all four factors into one observation list to evaluate psychosocial relations in the working environment. This observation list is considered to be one of the most comprehensive and objective lists.

We modified the TOMO as a questionnaire suitable for nurse anaesthetists, and coded the answers on a 5-point Likert scale: 1 = far too few, 2 = too few, 3 = enough, 4 = too much and 5 = far too much. The scale measures four work context factors: factor 1 – “career/rewards”, relates to financial rewards and development opportunities (7 items, α = 0.82); factor 2 – “relation with supervisor”, relates to the participation and support of the supervisor (6 items, α = 0.84); factor 3 – “task contents”, refers to the task responsibilities and skills that are part of the task (8 items, α = 0.76); and factor 4 – “social environment”, refers to interactions with colleagues (5 items, α = 0.69). Sample items included “possibilities to influence my career”, “appreciation by my supervisor”.

Job satisfaction was measured using three items (α = 0.72): satisfaction with the job, satisfaction with the organisation, and satisfaction with the department’s atmosphere, on a 4-point scale (1 = totally disagree, 2 = disagree, 3 = agree and 4 = totally agree). Previous studies support the usefulness of global measurements in single-shot surveys that assess the cognitive component of satisfaction [10].

Psychosomatic symptoms were measured using the permanent quality of life survey (POLS-questionnaire – Permanent Onderzoek Leef Situatie; α = 0.67), which was developed in 1997 and has been used by the Dutch government for longitudinal studies of psychosomatic symptoms amongst members of the Dutch labour force. Seven malaise symptom items were queried: gloom, anxiety, headache, fatigue, sleeplessness, pain in the back, and pain in joints or muscles (scale: yes = 1 and no = 0) [9]. The reported incidence of sickness absenteeism during the last year was analysed by coding the answers as 0 days (0), 1-7 days (1), 8-14 days (2), 15-28 days (3), 1-2 months (4), 3-7 months (5) and more than 7 months (6). Each nurse anaesthetist scored his/her own general health on a 5-point scale (1 = very bad to 5 = very good).

The Maslach Burnout Inventory (MBI) has a stable factor structure, and measures burnout as a specific type of occupational stress reaction amongst health care professionals. Its validity has been extensively investigated by different researchers, and it has been judged to be very reliable [11, 12]. In our study, we used the Dutch version, the MBI-Dutch Version (MBI-DV), which is considered as valid as the original one [13]. The questionnaire consisted of 16 work-related items (α = 0.86) that were rated on a 7-point Likert scale anchored “never” (1) to “always” (7). The prevalence of burnout and the differences between individuals with high and low scores in burnout were important, and therefore this study treated burnout as a one-dimensional variable.

The variable “work climate” was measured using the Gallup Institute questionnaire which contained 12 items (α = 0.67), which were rated on a 7-point Likert scale anchored by “never” (1) to “always” (7), and summed (range 12-84) [14].

Finally, nurse anaesthetists were asked about their intentions of leaving the job within the next two years (0 = no, 1 = yes).

The χ2 test was performed to determine if the demographic items were equally divided in both groups. If necessary, the non-parametric Mann-Whitney test was performed to establish any possible difference between the two groups. A p value <0.05 was considered significant.

RESULTS

Out of 2,000 Dutch nurse anaesthetists, 923 filled in the questionnaire (response rate of 46%) but 41 failed to complete it entirely and were excluded from further study. The study results were based on the responses of 882 nurse anaesthetists (431 women and 451 men) who filled in the questionnaire completely. Three hundred and thirty-four respondents were nurse anaesthetists without nursing backgrounds. The majority of the nurse anaesthetists (89.2%) were between 25 and 54 years of age, with a peak in the age range of 45-49 years (21.2%). Despite our best efforts, we were unable to retrieve the characteristics of the non-respondents.

All demographic items differed between both groups significantly at level p <0.001 (Table 1). For this reason, the non-parametric Mann-Whitney U test for two independent samples was used for work context factors, job satisfaction, health factors, work climate and turnover intention between nurse anaesthetists with a nursing background or otherwise (Table 2). The four work context factors (i.e. career planning/reward, relationship with supervisor, task contents and social environment) revealed no significant differences between the two groups. Job satisfaction, as well as health characteristics (i.e. burnout, psychosomatic symptoms, general health and sickness absenteeism), showed no evidence of significant differences between the two groups. Finally, work climate and turnover intention demonstrated also no significant differences between the group with and without a nursing background. In summary, controlling for the demographic items, the results for all variables showed no significant differences between nu
rse anaesthetists with and without a nursing background.

DISCUSSION

To our knowledge, this study is the first of its kind evaluating and comparing the perceptions of job requirements, job environment, personal competence and (organisational) standards amongst nurse anaesthetists with and those without a nursing background. Perceptions about work context factors, psychosomatic symptoms, burnout, sickness absence, general health and job satisfaction were similar in the two examined groups of nurses.

Our study did not measure the competence of the two groups in terms of health outcomes of patients or observed performance. However, several other studies have demonstrated a clear relationship between the performance of professionals and their perceptions of well-being, burnout, and job satisfaction. In 1981, Grey-Toft and Anderson [15] already demonstrated that patient management was related to job satisfaction and stress. Others reported that incompetent employees were associated with higher stress levels, a higher incidence of health complaints related to stress [6, 16]. Since our results provided evidence that burnout scores, psychosomatic symptoms scores, and absenteeism showed no statistically significant differences between nurse anaesthetists with and without a nursing background, this suggests an equal perception on the part of both groups of competence to perform their jobs [17].

Consequences of stress are minimised by emotional intelligence skills that equip the employee with more adaptive coping strategies [18]. Emotional intelligence skills – perceiving, understanding and expressing emotions – are often considered among the main competencies of nursing, and have an important place in nursing education. Yet in our study, the group of nurse anaesthetists without a nursing background, the ones who had never been exposed to the emphasis on emotional intelligence in nursing school, handled stress equally well as the group that had level 4 or 5 nursing degrees. This may emphasise the opinion, expressed in 1932 by Agatha Hodgins, the first president of the American Association of Nurse Anaesthetists, that the provision of anaesthesia related more closely to surgery and less to nursing [19].

Hackman and Oldham [5] developed the job characteristics model (JC-model) that relates the presence of certain job characteristics to an employee’s well-being and high level of job satisfaction. According to this model, core job characteristics (skill variety, task identity, task significance, autonomy, and job feedback) are essential for developing high levels of job satisfaction and employee well-being. The model states that job satisfaction reflects a person having sufficient knowledge and skills to perform the job without developing stress. Our study showed no evidence of different levels of job satisfaction between nurse anaesthetists with and without nursing backgrounds. According to the Hackman & Oldham’s theory, this would mean that both groups had the same perceptions on their knowledge and skills to adequately perform their jobs.

According to Kristof-Brown and colleagues [4], performance is related to Person-Organisation and Person-Group fit. This study measured several factors about organisational fit (climate) and found no statistically significant differences between the groups (nurse anaesthetists with and those without nursing backgrounds), which showed equal perceptions about PO fit, and performance of the two groups.

In Dutch hospitals, nurse anaesthetists perform the job in an identical way whether having a nursing background or not. Arbous and co-workers [20] concluded that Dutch anaesthetic practice, based on a team of physician anaesthesiologists and non-physician anaesthetists, resulted in a quality of care and safety comparable to international standards, and that the presence of a Dutch nurse anaesthetist, whatever background, significantly decreased the risk of perioperative morbidity and mortality. Neither Dutch law, the Dutch Society of Anaesthesiology, the management of Dutch hospitals, or Dutch anaesthesiologists differentiate between nurse anaesthetists with and without nursing backgrounds in allocating tasks, and consider members of both groups as having a similar level of competence.

This study has several limitations: 1) results show that nurse anaesthetists with and without nursing backgrounds according to their perceptions performed at a similar level; however, the actual performance of each group was not measured; 2) the mean age in the nurse anaesthetist group without a nursing background was significantly lower compared to the nurse anaesthetist group with a nursing background, because they started their studies, and, subsequently their careers as nurse anaesthetists, earlier. There were proportionately more women in the group of nurse anaesthetists without a nursing background, which may explain the higher incidence of part-time work (% of employment) in this group; and 3) when measuring PE fit in a multi-dimensional manner, it is possible that one aspect of the environment spills over into other aspects, resulting in a stronger or weaker PE fit effect. Further research consisting of a blind study of performance outcomes of individuals in the workplace, self-evaluations about feeli
ngs of self-esteem and self-efficacy, and PO fit for values and goals would provide this information.

CONCLUSIONS

1. No significant differences in perceptions between nurse anaesthetists with and those without nursing backgrounds were found, suggesting that competency-based training programs for non-physician anaesthesia professionals are more important for their future performance than a working experience in nursing.

2. Both channels of educational preparation of Dutch nurse anaesthetists appear to produce individuals who function similarly as professionals.

3. These findings may prove significant in solving the shortages in nursing personnel, and the problems in the recruitment of more anaesthesia professionals.

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1*Within the Dutch Nursing Profession, the system is split into three levels, i.e. nursing level 3, 4 and 5. Nursing level 3 is comparable to the State Enrolled Nurse (grade C) and requires a basic high school diploma, nursing level 4 and 5 (bachelor degree) require a senior high school level.

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REFERENCES

1.    Meeusen V, Van Zundert A, Hoekman J, Kumar C, Rawal N, Knape J: Anaesthesia team members: an European survey. Eur J Anaesthesiol 2010; 27: 773-779.

2.    Schneider B: Fits about fit. Int Rev Appl Psychol 2001; 50: 141-152.

3.    Maslach C, Schaufeli WB, Leiter MP: Job burnout. Annu Rev Psychol 2001; 52: 397-422.

4.    Kristof-Brown AL, Zimmerman RD, Johnson EC: Consequences of individuals’ fit at work: a meta-analysis of person-job, person-organization, person-group, and person-supervisor fit. Personnel Psychology 2005; 58: 281-342.

5.    Hackman JR, Oldham GR: Work redesign. Addison-Wesley Publ Comp, Reading, Massachusetts 1980.

6.    Houtman ILD, Kornitzer M, De Smet P, Koyuncu R, De Backer G, Pelfrene E, Romon M, Boulenguez C, Ferrario M, Origgi G, Sans S, Perez I, Wilhelmsen L, Rosengren A, Isacsson S, Őstergren P: The job stress, absenteeism and coronary heart disease European Cooperative study (the JACE-study)-Design of a multicenter prospective study. Eur J Public Health 1999; 9: 52-57.

7.    Kristof AL: Person-organization fit: an integrative review of its conceptualizations, measurement, and implications. Personnel Psychology 1996; 49: 1-49.

8.    Van Orden CYD, Gaillard AWK: TOMO: Toetsingslijst Mens & Organisatie. Zeist: Kerkebosch bv, 1994.

9.    Botterweck AAM: Psychische werkbelasting en gezondheidsklachten. Sociaal-economisch maandstatistiek 2003/10, Centraal Bureau voor de Statistiek 2003.

10.    Piko BF: Burnout, role conflict, job satisfaction and psychosocial health among Hungarian health care staff: a questionnaire survey. Int J Nurs Stud 2006; 43: 311-318.

11.    Barnett RC, Brennan RT, Gareis KC: A closer look at the measurement of burnout. J Appl Biobehaviour Res 1999; 4: 65-78.

12.    Bakker AB, Demerouti E, Schaufeli WB: Validation of the Maslach Burnout Inventory – General Survey: an internet study across occupations. Anxiety Stress Coping 2002; 15: 245-260.

13.    Roelofs J, Verbraak M, Keijsers PJ, De Bruin MBN, Schmidt AJM: Psychometric properties of Dutch version of the Maslach Burnout Inventory General Survey (MBI-DV) in individuals with and without clinical burnout. Stress and Health 2005; 21: 17-25.

14.    Buckingham M, Coffman C: First, break all the rules: what the world’s greatest managers do differently. Simon & Schuster, New York 1999.

15.    Grey-Toft and Anderson JG: Stress among hospital nursing staff: its causes and effects. Soc Sci & Med 1981; 15: 639-647.

16.    Peeters MCW, Montgomery AJ, Bakker AB, Schaufeli WB: Balancing work and home: how job and home demands are related to burnout. Int J Stress Manag 2005; 12: 43-61.

17.    Shimizutani M, Odagiri Y, Ohya Y, Shimomitsu T, Kristensen TS, Maruta T, Iimori M: Relationship of nurse burnout with personality characteristics and coping behaviours. Ind Health 2008; 46: 326-335.

18.    Montes-Berges B, Augusto JM: Exploring the relationship between perceived emotional intelligence, coping, social support and mental health in nursing students. J Psychiatr Ment Health Nurs 2007; 14: 163-171.

19.    Bankert M: Watchful care: a history of America’s nurse anesthetists. The Continuum Publ Comp, New York 2002.

20.    Arbous MS, Meursing AE, Van Kleef JW, De Lange JJ, Spoormans HH, Touw P, Werner FM, Grobbee DE: Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102: 257-268.

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address:

*Vera  Meeusen
Department of Anaesthesiology
Catharina Hospital – Brabant Medical School
Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven
the Netherlands
e-mail: meeusen44@hetnet.nl

received: 31.03.2011
accepted: 25.06.2011