Research

In this thesis, we argue that nursing workforce policy must evolve from its single-metric focus on nurse–to–patient ratios towards a systems-based approach: the Balanced Care Teams (BCT) framework. While the importance of adequate staffing is undisputable, ratio compliance alone cannot address the persistent variance in patient outcomes or the structural workforce challenges facing healthcare systems. Three critical limitations undermine the ratio-based paradigm: persistent global shortages render targets structurally unattainable; significant outcome variation persists even when targets are met; and operational focus on numerical compliance displaces the strategic planning required for long-term sustainability. The BCT framework reconceptualises team effectiveness as the strategic alignment of three interdependent components at the clinical micro system level: capacity (staffing levels, skill mix, experience, demographic composition); processes (collaboration, coordination, communication); and demands (workload, patient acuity). Balance emerges when these elements are strategically aligned to optimise outcomes for both patients and staff.

We operationalise this framework through several empirical and methodological contributions. Through a scoping review, we identified 35 factors across nine domains influencing team effectiveness, confirming that staffing levels represent only one dimension of a multifaceted system. in a multi-country observational study across 48 hospital units, we subsequently demonstrated that team composition variables and team stability influence outcomes. Age diversity within teams was associated with substantially lower fall rates, higher educational levels proved consistently protective for both patient safety and staff overtime, whilst team stability presented complex trade-offs between reduced absenteeism and increased overtime. To address the absence of objective measures for collaborative processes, we introduced the Structured Collaboration Index (SCI), a novel tool quantifying collaboration intensity using objective roster-derived data rather than subjective self-reports, distinguishing between core collaboration within stable subteams and extended coordination across team boundaries.

Beyond measurement, we examined workforce sustainability and implementation challenges. By investigating multiple job holding (MJH) among Belgian nurses, we found that 38% hold multiple jobs, with 44% of this activity occurring in non-nursing roles, paradoxically withdrawing skilled labour from healthcare during chronic shortages. The primary drivers were push factors: 64% of respondents cited financial insecurity and inadequate compensation as their main motivator, framing MJH as a compensatory response to systemic deficits rather than individual preference. The finding that master's-educated nurses were significantly more likely to engage in MJH further suggests a status–compensation mechanism linked to perceived disparities within hierarchical healthcare organisations. Through a longitudinal evaluation, we demonstrated that strategic workforce transformation requires multi-year commitment; initial efforts showed mixed results, but sustained investment eventually yielded significant improvements in management support, social capital, and nurse-reported quality of care. An implementation analysis of a BCT-based decision support system revealed that evidence-based innovations fail not from insufficient evidence but from sociotechnical fragmentation: technological silos created by vendor lock-in and legacy systems, organisational barriers that position nursing as peripheral to strategic objectives, and managerial hesitance rooted in crisis-mode operations and fear of punitive use of performance data.

Our synthesis demonstrates that fragmentation, whether of teams, roles, schedules, data systems, or organisational responsibilities, imposes measurable costs on patient safety and staff sustainability that ratio compliance cannot address. MJH causes employment rate dispersion, structurally impeding the relational continuity necessary for developing transactive memory systems, which are essential for implicit coordination and safe care delivery. This provides a plausible mechanism explaining why employment rate dispersion increases adverse event risk. The methodological innovations transform team composition from an abstract concept into quantifiable, optimisable parameters, enabling the field to move beyond ratio-only approaches to workforce design. Critically, these findings can be understood within a broader structural governance problem: nursing is consistently treated as a cost to minimise rather than a strategic asset to develop, rendering long-term workforce investments unfundable within current organisational frameworks. Therefore, workforce policy must shift from simply counting nurses to designing the conditions under which balanced care teams can function reliably. This requires supplementing ratio policies with team-level indicators of composition, stability, and collaboration structure; mandating strategic positioning of nursing leadership with executive authority and budgetary control; and reforming healthcare financing to recognise long-term workforce investment returns