More Evidence Nurse Staffing and Education Reduce Patient Deaths

By Debra Wood, RN, contributor

February 26, 2014 - European hospitals with better nurse staffing and more nurses with bachelor’s degrees enjoyed lower patient mortality rates after common surgeries, according to the latest study from Linda H. Aiken and colleagues that published in The Lancet this week.

Linda Aiken found reduced nurse staffing led to higher mortality rates.
Linda Aiken, PhD, FAAN, FRCN, RN, said U.S. hospitals should learn from cost-cutting in Europe that reduced nurse staffing and led to higher mortality rates.

“Our results suggest that the assumption that hospital nurse staffing can be reduced to save money without adversely affecting patient outcomes may be foolish at best, and fatal at worst,” said Aiken, PhD, FAAN, FRCN, RN, professor of nursing and sociology and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Pennsylvania in Philadelphia.

Many hospitals in Europe had sought to reduce costs by decreasing nurse staffing, and a couple of smaller studies reported notable changes in patient outcomes.

“What we find in Europe is those hospitals that reduced their staffing had the worst mortality,” Aiken said. “We can learn important things from different countries.”

The Lancet paper shows that reducing nurse staffing is a bad idea, Aiken added, and not one that the United States would want to pursue if our national goal is to reduce adverse outcomes associated with surgery.

“Hospitals should take notice because when budgets are tight, cutting back on nurses is often the first step, but one that can have disastrous consequences for patients,” Aiken said.

The study, part of the RN4CAST collaborative, is the largest investigation of nursing and hospital outcomes in Europe. Aiken co-leads RN4CAST, a European collaborative to study nursing workforce issues, with Walter Sermeus, a professor at Catholic University of Leuven in Belgium. The U.S. National Institutes of Health and the European Union have provided funding.

The researchers reviewed medical records for 422,730 patients aged 50 years or older discharged after common surgery such as hip or knee replacement, appendectomy, gallbladder surgery and vascular procedures in nine European countries. They surveyed more than 26,500 nurses practicing in 300 hospitals.

The analysis found that every extra patient added to a nurse’s average workload increases the chance of surgical patients dying within 30 days of admission by 7 percent, and a 10 percent increase in the proportion of nurses holding a bachelor’s degree is associated with a 7 percent decrease in the risk of death.

Patient–nurse staffing ratios varied from 3.4 to 17.9 patients per nurse. Norway had the lowest mean staffing ratio at 5.2 patients to one nurse, with a range of 3.4 to 6.7. Spain had the highest mean at 12.7 patients per nurse, with a range of 9.5 to 17.9.

The percentage of nurses with a bachelor’s degree also showed wide variation, with a mean of 52 percent and a range of zero to 100 percent. Switzerland had a mean of 10 percent of nurses with a BSN, and at the other extreme, 100 percent of nurses in Norway and Spain have earned bachelor’s degrees.

“In every country we studied there was wide variation in staffing and in proportion of BSN nurses, and that accounted for the wide variation in mortality,” Aiken said. “In some hospitals in Europe, more than 7 percent of patients died.”

The overall percentage of patients who died in a hospital within 30 days of admission was low, with an average of 1 percent to 1.5 percent.

“There are substantial numbers of lives that could be saved,” said Aiken, explaining that general surgery patients are expected to live. “You would expect the mortality rate to be zero.”

In hospitals where nurses care for an average of six patients each, and the proportion of nurses with bachelor’s degrees is 60 percent or greater, the risk of hospital deaths would be almost 30 percent lower than in hospitals where nurses care for an average of eight patients, and in which only 30 percent of nurses have bachelor’s degrees.

The results are similar to prior studies about nurse staffing and education Aiken has conducted in the United States, despite the fact the nine European countries have different healthcare systems and spend less than the United States on it.

“We find almost the same thing about the association between nursing and staffing and education,” Aiken said. “This is a strong relationship that cannot be brushed aside.”

Aiken referenced a 2014 University of Connecticut School of Medicine study about National Trends in Patient Safety, published in the New England Journal of Medicine, which found no significant reduction in adverse-event rates for surgical patients in the United States.

“The U.S. needs to start looking at different strategies to improve outcomes, and one of those strategies is nursing,” Aiken said. “We are not going to make progress on improving patient safety and quality of care in the U.S. until we take our own research seriously and act on it.”

Aiken added that many hospitals need to ramp up nurse staffing levels and increase the percentage of nurses with bachelor’s degrees to improve patient care. Average staffing in the United States is 5.5 patients to one nurse, but U.S. hospitals have a 12-fold difference in staffing and mortality rates.

“This variation is bad for patients, especially patients who end up in the worst staffed hospitals with few BSN nurses,” said Aiken, adding, “Nurses are important and essential, and we need to invest in them, even when times are bad.”

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