Elsevier

The Lancet

Volume 383, Issue 9931, 24–30 May 2014, Pages 1824-1830
The Lancet

Articles
Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study

https://doi.org/10.1016/S0140-6736(13)62631-8Get rights and content

Summary

Background

Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures.

Methods

For this observational study, we obtained discharge data for 422 730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26 516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics.

Findings

An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031–1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886–0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients.

Interpretation

Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths.

Funding

European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.

Introduction

Constraint of health expenditure growth is an important policy objective in Europe despite concerns about adverse outcomes for quality and safety of health care.1, 2 Hospitals are a target for spending reductions. Health-system reforms have shifted resources to provide more care in community settings while shortening hospital length of stay and reducing inpatient beds, resulting in increased care intensity for inpatients. The possible combination of fewer trained staff in hospitals and intensive patient interventions raises concerns about whether quality of care might worsen. Findings of the European Surgical Outcomes Study3 across 28 countries recently showed higher than expected hospital surgical mortality and substantial between country variation in hospital outcomes.

Nursing is a so-called soft target because savings can be made quickly by reduction of nurse staffing whereas savings through improved efficiency are difficult to achieve. The consequences of trying to do more with less are shown in England's Francis Report,4 which discusses how nurses were criticised for failing to prevent poor care after nurse staffing was reduced to meet financial targets. Similarly, results of the Keogh review5 of 14 hospital trusts in England showed that inadequate nurse staffing was an important factor in persistently high mortality rates. Austerity measures in Ireland and Spain have been described as adversely affecting hospital staffing too.6, 7

Research that could potentially guide policies and practices on safe hospital nurse staffing in Europe has been scarce. Jarman and colleagues8 reported an association between large proportions of auxiliary nurses (which implies a low overall mix of nursing skill) and high mortality in hospitals in England. Rafferty and colleagues9 noted that low hospital mortality in England after common surgeries was associated with nurses each caring for few patients. Research in Belgium10 found hospital mortality after cardiac surgery was significantly lower in hospitals with lower patient to nurse staffing ratios and in hospitals with a higher proportion of nurses with bachelor's education than in hospitals with higher staffing ratios and fewer nurses with bachelor's education. Likewise, data from a Swiss study11 suggested significantly increased surgical mortality associated with inadequate nurse staffing and poor nurse work environments.

This nascent but growing scientific literature about nursing outcomes in Europe is complemented by research from North America showing that improved hospital nurse staffing is associated with low mortality.12 Additionally, growing evidence exists that bachelor's education for nurses is associated with low hospital mortality.13, 14, 15, 16, 17

Research into nursing has had little policy traction in Europe compared with the USA where almost half the 50 states have implemented or are considering hospital nurse staffing legislation.18, 19 On the basis of findings showing improved outcomes for patients, the Institute of Medicine recommended that 80% of nurses in the USA have a bachelor's degree by 2020,20 and hospitals have responded with preferential hiring of bachelor's nurses. European decision makers might be unclear about the applicability of research done in individual countries in Europe or North America to Europe more generally. Specifically, scientific evidence is needed to inform the continuing European Union policy debate about harmonisation of professional qualifications for nurses.21

RN4CAST, funded by the European Commission, was designed to provide scientific evidence for decision makers in Europe about how to get the best value for nursing workforce investments, and to guide workforce planning to produce a nurse workforce for the future that would meet population health needs.22 Investigators of the study of 488 hospitals in 12 European countries noted substantial variation between countries with regards to patient to nurse workloads and the percentage of nurses qualified at the bachelor's level.23 These variations in nursing resources are important predictors of patients' satisfaction with their care and in nurses' assessments of quality and safety of care.24

We aimed to assess whether differences in patient-to-nurse workloads and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data are associated with variation in hospital mortality after common surgical procedures. The nine countries are representative of variation in Europe with respect to organisation, financing, and resources given to health services. The study's findings provide previously unavailable evidence to guide important decisions about improvement of hospital care in Europe in the context of scarce resources and health-system reforms.

Section snippets

Study setting

Data for this observational study were from administrative sources on hospital patients and characteristics of hospitals, and surveys of 26 516 bedside care professional nurses done in 2009–10 in 300 hospitals in nine European countries (Belgium, England, Finland, Ireland, the Netherlands, Norway, Spain, Sweden, and Switzerland). Similar patient discharge data consistent with the patient mortality protocol were not available for three RN4CAST countries (Germany, Poland, and Greece). The study

Results

We obtained mortality data for 422 730 patients; the number of hospitals and surgical discharges varied across countries (table 1). The percentage of surgical patients who died in the hospital within 30 days of admission was 1·3% across the nine countries combined, and was lowest in Sweden and highest in the Netherlands (table 1).

Response rates for surveys of nurses ranged from less than 40% (2990 of 7741) in England, to nearly 84% (2804 of 3340) in Spain, and averaged 62% (29 251 of

Discussion

Our findings shows that an increase in nurses' workload increases the likelihood of inpatient hospital deaths, and an increase in nurses with a bachelor's degree is associated with a decrease in inpatient hospital deaths (panel). Findings of the RN4CAST study showed more variation in hospital mortality after common surgical procedures in European hospitals than is generally understood. Variation in hospital mortality is associated with differences in nurse staffing levels and educational

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