The impact of nurse staffing levels and nurse’s education on patient mortality in medical and surgical wards: an observational multicentre study

Abstract

BackgroundGrowing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Current research is limited to studies using hospital level data or without proper adjustment for confounders which makes the translation to practice difficult.MethodIn this observational study we analysed retrospectively the control group of a stepped wedge randomised controlled trial concerning 14 medical and 14 surgical wards in seven Belgian hospitals. All patients admitted to these wards during the control period were included in this study. Pregnant patients or children below 17 years of age were excluded. In all patients, we collected age, crude ward mortality, unexpected death, cardiac arrest with Cardiopulmonary Resuscitation (CPR), and unplanned admission to the Intensive Care Unit (ICU). A composite mortality measure was constructed including unexpected death and death up to 72 h after cardiac arrest with CPR or unplanned ICU admission. Every 4 months we obtained, from 30 consecutive patient admissions across all wards, the Charlson comorbidity index. The amount of nursing hours per patient days (NHPPD) were calculated every day for 15 days, once every 4 months. Data were aggregated to the ward level resulting in 68 estimates across wards and time. Linear mixed models were used since they are most appropriate in case of clustered and repeated measures data.ResultsThe unexpected death rate was 1.80 per 1000 patients. Up to 0.76 per 1000 patients died after CPR and 0.62 per 1000 patients died after unplanned admission to the ICU. The mean composite mortality was 3.18 per 1000 patients. The mean NHPPD and proportion of nurse Bachelor hours were respectively 2.48 and 0.59. We found a negative association between the nursing hours per patient day and the composite mortality rate adjusted for possible confounders (B = − 2.771, p = 0.002). The proportion of nurse Bachelor hours was negatively correlated with the composite mortality rate in the same analysis (B = − 8.845, p = 0.023). Using the regression equation, we calculated theoretically optimal NHPPDs.ConclusionsThis study confirms the association between higher nurse staffing levels and lower patient mortality controlled for relevant confounders.

Working Excessively and Burnout Among Nurses in the Context of Sick Leaves

“…A shortage of nursing personnel severely affects the quality of medical services. This problem has been trending in most countries around the world (Buerhaus et al, 2007;Haddad and Toney-Butler, 2019;Haegdorens et al, 2019). Poland, however, has one of the lowest indicators of practicing nurses per 1000 residents among the OECD countries.…”

Case for hospital nurse-to-patient ratio legislation in Queensland, Australia, hospitals: an observational study

“…There is strong evidence over decades internationally showing that patients cared for in hospitals with more patients per nurse have worse outcomes including mortality, adverse events, infections and readmissions, compared with similar patients in hospitals with fewer patients per nurse. [1][2][3][4][5][6][7][8][9][10] Responding to this growing evidence, the International Council of Nurses released a position statement on safe staffing in 2018, encouraging nursing organisations and governments to establish evidence-based staffing systems and policies. 11 A policy intervention often discussed, but rarely implemented is setting minimum nurse-to-patient ratios.…”

Association between the bed-to-nurse ratio and 30-day post-discharge mortality in patients undergoing surgery: a cross-sectional analysis using Korean administrative data

“…The major limitation of this study is related to the measurement of nurse staffing levels. International studies have measured nurse staffing levels in various ways, such nursing hours per patient day, nurse staffing by shift or the occupancy rate, and the education level of nurses [18,23,32]. However, this study only used the bed-to-nurse ratio because information on other indices was unavailable in the data used in this study; furthermore, this study could not control for the individual characteristics of nursing organizations and nurses due to limitations in the data.…”

“…As such, in studies conducted in Korea, nurse staffing has consistently been found to be associated with multiple measures of mortality. Studies on nurse staffing and in-hospital deaths in other countries revealed associations between higher staffing levels of registered nurses and lower patient mortality rates [22,23]. Therefore, if an appropriate level of nurse staffing is secured, the mortality rate of patients could be expected to decrease.…”