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Nurse cuts 'linked to death rates', says major study


Nursing cutbacks are directly linked to higher patient death rates in hospitals, a major study has found.

Every extra patient added to a nurse’s workload increases the risk of death within a month of surgery by 7%, according to data from 300 European hospitals in nine countries.

The situation is made worse by employing poorly qualified nurses, the research showed. But nurses had university degrees, it went a long way towards making up for reduced staffing levels.

A 10% increase in the proportion of nurses holding a bachelor degree was associated with 7% lower surgical death rates.

The findings, published in The Lancet journal, included figures for 30 English hospitals showing that on average every one of their nurses looked after around nine patients.

“Our findings emphasise the risk to patients that could emerge in response to nurse staffing cuts”

Professor Linda Aiken

In some other countries the patient-to-nurse ratio was significantly smaller. Norway had a ratio of 5.2 to one, the Irish Republic 6.9, the Netherlands seven and Finland and Sweden 7.6.

Spain appeared to have the most overworked staff, with an average 12.7 patients per nurse. But in Spain every nurse had a bachelor degree, compared with only 28% in England at the time the data was collected in 2009-10.

Since September last year, every newly qualified nurse in the UK has had to possess a university degree.

Professor Linda Aiken, from the University of Pennsylvania School of Nursing, who led the research, said: “Our findings emphasise the risk to patients that could emerge in response to nurse staffing cuts under recent austerity measures, and suggest that an increased emphasis on bachelor’s education for nurses could reduce hospital deaths.”

Professor Linda Aiken

Professor Linda Aiken

The study analysed information on more than 420,000 patients admitted to hospitals in Belgium, England, Finland, the Irish Republic, the Netherlands, Norway, Spain, Sweden, and Switzerland.

Researchers compared nurse workload and education and patient outcomes, taking into account a number of factors that could influence the result.

These included the age and sex of patients, types of surgical procedure, chronic conditions, and the kind of technology available in a hospital.

The overall percentage of surgical patients who died within 30 days of admission was low, ranging between 1% and 1.5% per country. In England, the average rate was 1.4%.

However, in every country death rates varied significantly between individual hospitals, with some losing up to 7% of surgical patients after 30 days.

The highest risk of death after surgery was found in hospitals where nurses with lower levels of education cared for the most patients, said the researchers.

A comparison was made between hospitals where every nurse cared for an average of six patients and the proportion of degree-educated staff was at least 60%, and those where nurses looked after eight patients each and just 30% had bachelor degrees.

The hospitals with lighter workloads and more qualified nurses were expected to have 30% lower surgical death rates.

“Our data suggest that a safe level of hospital nursing staff might help to reduce surgical mortality, and challenge the widely held view that nurses’ experience is more important than their education,” Dr Aiken added.

The European findings closely mirrored similar trends seen in the US, said the researchers.

The findings follow a survey of 526 nurses by Nursing Times earlier this month, which found 57% believed their wards were “dangerously understaffed”.

Peter Carter, chief executive of the Royal College of Nursing (RCN), said: “It is worrying to see that researchers found the mean ratio of patients to nurses in England is above eight, as we know that this can compromise patient safety.”

Dr Peter Carter

The findings also supported the UK’s recent decision to make nursing an all-graduate profession, Dr Carter added.

“Compassion and caring will always be at the heart of nursing practice and nurse training,” he said. “However, the demands of modern health care mean that this must be backed up by a higher level of education so that patients, who often have complex needs, receive skilled and compassionate care..

“Modern medicine means that a nurse’s role is far more technical and requires complex decision making which demands a degree level education as well as the practical experience which currently makes up at least half of a nursing degree.”

In November, the government’s response to the inquiry into Stafford Hospital stopped short of introducing a minimum staff-patient ratio on wards or enshrining this in law.

Organisations, including the RCN, have called for a minimum of one nurse for every eight patients.

“This research comprehensively rebuts the myth that degree-level education for nurses is a retrograde step”

Professor Ieuan Ellis

Professor Ieuan Ellis, chair of the Council of Deans of Health, which represents all UK university faculties providing education and research for nursing and midwifery, also commented on the importance of the findings on degree nursing.

Professor Ieuan Ellis

Professor Ieuan Ellis

He said: “This research comprehensively rebuts the myth that degree-level education for nurses is a retrograde step.

“In fact, this study shows that education to bachelor’s level is a significant protective factor in reducing unnecessary hospital deaths.”


Study summary at a glance

Background: The RN4CAST study was designed to inform financial decision-making about nursing.

Method: Researchers obtained discharge data for 422,730 patient aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education.

Results: An increase in a nurses’ workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7%, and every 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7%.

Conclusion: 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.

Source: The Lancet


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Readers' comments (28)

  • Tinkerbell

    Bad news day. And still it goes on. My hand is tightening around my imaginary baseball bat cos' someone in the Condem party needs an imaginary whacking. Want to get elected - think like a clown.

    Paraphrasing 'Sadly if people aren't allowed to protest peacefully they will be forced to violence' - JFK

    This ain't over till it's over and the public are waking up to the effect of all these cutbacks and loss of services.

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  • Well, would any senior nurse, particularly those who ruthlessly implemented the staffing cuts, like to comment on the above? I think we will discover more evidence of the relationship between poor care and staffing levels. So, any senior nurses out there who might want to admit they were wrong, nows the time to come clean.

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  • Very interesting reading.
    As is often the case the issues are far more complex and varied than just being down to whether the nurse holds a degree or not.
    The study does not say how many ancillary staff are working on the shifts with the degree nurses.
    The study does not say how they have been able to compare the state of the NHS funding v. how all these other countries fund their health services.
    I think the study raises more questions than it apparently answers.

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  • You can have degrees coming out your ears but if you are the only qualified nurse looking after quite a few poorly patients at the same time then patients are going to suffer as they wait for their medication, IV antibiotics etc. Also I have yet to come across any nurse holding a degree in compassion.

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  • Isn't it amazing: I must've missed Carter and his gang calling for 1:8 staffing levels when he visited Mid-Staffs as patients were suffering and lying dying.

    Seems reasonable to me: the more nurses you have the better the outcome. I suppose it follows too that the higher the qualification the better.

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  • It needed a study to state the obvious?? I have managed to work for the last 25 yrs in Critical Care without a degree-It does not require a degree to be a nurse-It requires a certain amount of intelligence,common sense oh and yes a caring attitude-Nurse researchers have not worked near a patient's bedside in years -

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  • I am more than affronted by the term 'poorly qualified nurses' in this article used to suggest that a nurse without a degree is inferior in qualification to those with a degree.

    On qualifying "newly qualified nurses" were soon expected to take charge of a ward, perform drug rounds, perform aseptic techniques and provide general care for patients. After all, that was what we had trained for three years to do and during the course of our 'poor education' we undertook assessments that allowed us to practice safely once qualified. Sadly, things have changed and Newly Qualified degree nurses come out ill equipped to perform the duties required.

    The average degree nurse takes around six months to attain the knowledge needed to be competent in basic procedures such as medicine administration, and in that time are nurtured and carried by qualified nurses who fall into your category of 'poorly qualified'

    Maybe the 'poorly qualified' nurses should consider giving up their mentoring roles and qualifications and see how many student nurses the universities can put through the system without their support - both as students and as newly qualified nurses.

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  • i couldn't agree more with the sentiment above. I have been a qualified nurse for 37 years. Nurses have always been at the for front of innovation, care and compassion. Nurses have alaways had further extended roles in the past which has required further education and training, these qualifications have supported and enhanced care for all patients. Where does the wealth of experience and knowledge go to, according to these so called studies. Newly qualified nurses may have a degree, but lack the skill and experience to put their degree into practice with a confident and compassionate manner.I have noticed on the wards that degree level qualified staff have to rely on their more experienced staff members to ensure that timely and accurate care can be provided, whom don't have a degree!!

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  • surely even with a degree nurses need the time for their maturity and experience to develop. those of us who do not have degrees have also taken some years to develop our further knowledge, experience and skills and confidence. maybe we are asking too much of our new young graduate nurses.

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  • No **** Sherlock, the most well qualified staff cannot improve outcome if they cannot even get to the patient. It is a balance that is required but massive increases in the numbers of non-registered staff without the necessary education will not help. Foundation degree should be the minimum for HCA staff, and far higher proportions of Registered Bachelors and Masters Degree Nurses should be caring for patients.

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