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Associations between structure, process and end-point indicators of the health service (completed)

This PhD project is part of the Norwegian branch of RN4Cast. More information about the Norwegian branch is published on the website of the Norwegian Knowledge Centre for Health Services

About the project

The RN4CAST project  (nurse forecasting: human rescource planning in nursing) is funded by the 7. Framework Programme of the European Commission, and involves 11 EU countries and three non-European partner countries in addition to Norway ( The project is conducted by a consortium of researchers from the participating countries and coordinated by the Centre for Health Services and Nursing Research, Katholieke Universiteit Leuven, Belgium and Center for Health Outcomes and Policy Research from the University of Pennsylvania (USA) as vice-coordinator.


The process-structure-outcome model described by Donabedian serves as theoretical framework for the data collection in this PHD-project. Structural factors as size, activity, staffing, nurses’ practice environment and patient safety culture are collected to describe the hospitals and associations between these structural characteristics and performance indicators as 30-day mortality and surgical site infections will be studied (Figure 1).

Figure 1 Modification of Donabedian's model


The study has an ecological design in which a combination of cross-sectional surveys and use of registry data is included in a comparison between 35 Norwegian hospitals. Organisational characteristics of the hospitals, such as staffing and activity, are taken from Statistics Norway. Through a questionnaire that was developed in the United States and included in the RN4Cast study, data on nurses' practice environment at 35 Norwegian hospitals is gathered. Information about 30 day mortality will be obtained from the Norwegian Knowledge Centre for Health Services. Data about surgical site infection incidence, will be estimated from NOIS (Norwegian surveillance system for infections in the hospital service)


The recognition that a large number of patients are harmed when cared for in hospitals, has resulted in national and international efforts to improve patient safety. Most patient injuries are not permanent, but 5% - 10% of the injuries are fatal. Health care associated infections represent a considerable amount of patient injuries, and figures from European Centre for Disease Prevention and Control (ECDC) show that health care associated infections occur in 1 of 20 hospitalized patients per year in the EU. Figures from the Norwegian surveillance system for infections in the hospital service (NOIS) indicate that this problem is present in Norway as well.

Patient injuries are not necessarily result of one single factor, as related to a particular health care worker, patient or equipment. The interaction between a number of factors are often involved, and illustrate the complexity of the health care service. This makes it difficult to identify and analyze patient safety indicators and raise the question about how to measure patient safety in health care. The last decade, nurses’ practice environment has been a research issue, and both nurse staffing and educational level have been associated with hospital mortality. Internationally, there is a growing body of evidence on associations between health workers practice environment, patient safety culture and patient safety. However, the lack of research in a Norwegian context and variations in the existing evidence, leave a need for further research.


  • The Norwegian Nurses Organisation


  • RN4Cast
  • The Norwegian Knowledge Centre for the Health Services

Start - Finish

15.09.2009 – 15.09.2013 

Published May 21, 2011 6:05 PM - Last modified Feb. 17, 2020 10:12 AM



Christine Tvedt


Detailed list of participants