Lancet report on nurse staffing and education levels

The Lancet reported today the results of a study in 9 European countries documenting that hospital nurse staffing and the proportion of nurses with bachelor’s education are associated with significantly fewer deaths after common surgery.   A team of researchers led by the University of Pennsylvania School of Nursing in the U.S. and Catholic University of Leuven in Belgium, and including Prof Anne Scott and her team from Dublin City University, found that every one patient increase in patient to nurse ratios was associated with a 7% increase in deaths, while having a better educated nurse workforce is associated with fewer deaths.  Every 10% increase in bachelor’s degree nurses is associated with a 7% decline in mortality.

This study of close to a half million surgical patients found that patients in hospitals in which 60 percent of nurses had bachelor’s degrees and cared for an average of six patients had nearly a one-third lower risk of death after common inpatient surgical procedures than patients in hospitals where half as many nurses had bachelor’s degrees and cared for an average of eight patients each.  The RN4CAST study, funded by the European Union and the National Institute of Nursing Research, National Institutes of Health, concluded that in Europe, as in the U.S., failing to invest in bachelor’s nurse education and attempts to cut costs by reducing nurse staffing may put hospitalized patients at greater risk of dying.

“This study draws attention to the importance of examining both patient-to-nurse ratios and the education levels of nursing staff in our hospitals, and in the individual wards in those hospitals, as a possible means of improving patient outcomes,” said Prof Anne Scott, Dublin City University.  “Ireland has invested in nurse education since the Commission on Nursing in 1998. It is now time to recognize that nurse education levels are linked to patient outcomes. Our results suggest that the assumption that hospital nurse staffing can be reduced to save money without adversely affecting patient outcomes may be misguided at best, and fatal at worst. This is crucial information for hospital managers given the significant reduction in nurse staffing in Irish hospitals since 2008, and particularly in light of the ongoing moratorium on staffing. “

The study’s results closely dovetail with research conducted in the U.S.  which served as a catalyst for public and private responses to improve nurse staffing and nurses’ education. Nearly half the states in the U.S. “have implemented or are considering hospital nursing staffing legislation and/or regulation,” the study’s authors report. Additionally the Institute of Medicine of the U.S. National Academy of Sciences has recommended a U.S. national nurse workforce that is 80 percent bachelor’s educated by 2020.

Similar initiatives are much less common in Europe.  The recent Francis and Keogh reports in England investigating poor outcomes for hospital patients concluded that inadequate nurse staffing contributed to preventable deaths, reported the authors.

In Europe, the proportion of hospital nurses with bachelor’s degrees varies significantly across countries.  Ireland has moved to an all graduate nursing profession; with the first national, registration group of nurses graduating with a BSc in nursing in 2006.  However there is still considerable within hospital and between hospital variation in the percentages of nurses with degree level education. Some hospitals studied had no nurses with bachelor’s qualifications while all nurses in Norway and Spain are required to be bachelor’s qualified.  The European Parliament, in its continuing efforts to foster occupational mobility across EU member countries, side-stepped the issue of nurse qualifications in October 2013 by approving two very different educational pathways for nurses.  One newly recognized pathway leads to bachelor’s education but the other maintains a vocational training track to prepare nurses after only 10 years of secondary school.  The findings of the Lancet paper suggest that continued EU recognition of vocational training for nurses may adversely affect patient outcomes and nurses’ access to university education in some countries.