Nurse staffing, education tied to hospital death rate

"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," says Anne Marie Rafferty. (Credit: iStockphoto)

Hospitals with more nurses, and more nurses with degrees, report significantly fewer deaths after routine surgery, research shows.

A new study conducted across nine European countries reports that every 10 percent increase in the number of bachelor’s degree-educated nurses within a hospital is associated with a seven percent decline in patient mortality.


Patients in hospitals, in which 60 percent of nurses had bachelor’s degrees and where nurses cared for an average of six patients, had almost 30 percent lower mortality than patients in hospitals in which only 30 percent of nurses had bachelor’s degrees and nurses cared for an average of eight patients.

Published in The Lancet, the study shows that, in hospitals in England, an average only of 28 percent of bedside care nurses had bachelor’s degrees, among the lowest in Europe, which averages 45 percent.

Increasing the production of graduate nurses is necessary if the National Health Service is to realize the potential of lower patient mortality and fewer adverse patient outcomes, says Professor Peter Griffiths, chair of Health Services Research at the University of Southampton.

“The study highlights two very important issues. One is that the number of trained nurses on hospital wards is a crucially important factor in ensuring that patients are safe; it makes it absolutely clear that low staffing levels are dangerous.

“The other issue that is highlighted is nurse education. There has been a massive backlash against educating nurses to degree level. These findings from nine European countries shows that hospitals, which employ more degree qualified nurses, have a lower rate of mortality compared to hospitals with fewer degree qualified nurses.

“In the face of these figures, it is hard to conclude that degree educated nurses are to blame for failings in the NHS. It is more likely that, where nursing has failed, it is because of inadequate resources and support by NHS managers in some hospitals.”

Quantity and quality

Professor Anne Marie Rafferty of the Florence Nightingale School of Nursing and Midwifery at King’s College London, and the lead investigator for England on the study, says: “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.

“It is vital that investment in nurse staffing is evidence based. Our evidence demonstrates that it is not only quantity but the quality of the workforce that counts. The size and scale of these findings across the EU confirms previous evidence from England demonstrating that better educated nurses, caring for fewer patients, with lower workloads reduces patient mortality.

“We demonstrate that an increase in nurses’ workloads by one patient increases the likelihood of inpatient hospital mortality by seven percent, and a 10 percent increase in bachelor’s degree nurses is associated with a decrease in odds on mortality by seven percent, clearly showing that an increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths.

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

The study was designed to assess whether differences in patient to nurse ratios and nurses’ educational qualifications, in nine countries with similar patient discharge data, are associated with variation in hospital mortality after common surgical procedures. The study also shows that every one patient increase in patient to nurse ratios is associated with a 7 percent increase in deaths.

The study, funded by the European Union and the National Institute of Nursing Research, National Institutes of Health, concludes that in England, as in the US, failing to invest in bachelor’s degree nurse education and attempts to cut costs by reducing nurse staffing may put hospitalized patients at greater risk of dying.

Source: University of Southampton