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

Aiken, LH and Sloane, DM and Bruyneel, L and Van den Heede, K and Griffiths, P and Busse, R and Diomidous, M and Kinnunen, J and Kozka, M and Lesaffre, E and McHugh, MD and Moreno-Casbas, MT and Rafferty, AM and Schwendimann, R and Scott, PA and Tishelman, C and van Achterberg, T and Sermeus, W (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. LANCET, 383 (9931). pp. 1824-1830. ISSN 0140-6736

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Abstract

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.

Item Type: Article
Additional Information: NOTICE: this is the author’s version of a work that was accepted for publication in Lancet. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in Lancet, 383(9931) May 2014 DOI:10.1016/S0140-6736(13)62631-8
Uncontrolled Keywords: 11 Medical And Health Sciences
Subjects: R Medicine > RT Nursing
Divisions: School of Nursing & Allied Health
Publisher: ELSEVIER SCIENCE INC
Related URLs:
Date Deposited: 05 Mar 2015 14:27
Last Modified: 19 Jun 2015 08:10
DOI or Identification number: 10.1016/S0140-6736(13)62631-8
URI: http://researchonline.ljmu.ac.uk/id/eprint/565

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