We should be intolerant of inequalities in access to nursing and set national standards for education that focus on the capability of the workforce through education, say Anne Marie Rafferty and Peter Griffiths
Both hospital nurse staffing levels and education, in terms of the proportion of nurses with a bachelor’s degree, are associated with the chances of patients dying after common surgery. Our recent study of European hospitals, published in The Lancet, found that every additional patient per nurse was associated with a 7% increase in deaths, while every 10% increase in the proportion of nurses with a bachelor’s degree that a hospital employs is associated with a 7% decline in mortality.
These findings, from close to a half million patients in nearly 500 hospitals, suggest patients in hospitals where 60% of nurses had degrees and cared for an average of six patients each have nearly a one-third lower risk of death after surgery than those in hospitals where half as many nurses had degrees and cared for an average of eight patients each. The RN4CAST study concluded that failing to invest in graduate nurse education and attempts to cut costs by reducing nurse staffing may put hospitalised patients at greater risk of dying.
“Failing to invest in graduate nurse education and attempts to cut costs by reducing nurse staffing may put hospitalised patients at greater risk of dying”
One of the concerns raised by the study is the variation in staffing levels in England. Average nurse-to-patient ratios varied across hospitals from 1:5.5 to 1:11.5. There are several worrying aspects to this. The first is the variation within hospitals is even greater than the variation between hospitals. Although the variation may be thought to reflect variation in patient need, the finding that variation in staffing levels are associated with variation in death rates suggests hospitals are not all getting this right. The second is the degree to which managers are aware that such variation exists. Feeding back mortality rate data to clinicians has been shown to boost performance. Applying the same principle to staffing levels would at least stimulate debate and be a vital step in opening the black box of staffing levels.
Similarly, levels of graduates in English hospitals varied from 10-49% with an average of 28%. Again, this variation was associated with variation in mortality. It is likely such variations reflect different investment patterns, and variation in the value employers place on degree nursing.
The link between education and numbers has consequences for workforce sustainability. The recent draft NICE guidance on safe staffing is intended to enhance transparency, but caution is required lest the debate focuses too narrowly on clinical care and the short term. Nurses care for patients but they also teach students and play a vital role in producing the next nurse generation. Little attention has been given to staff training needs. We know staffing impacts on the quality of the practice environment and outcomes for qualified staff. It is likely this effect also extends to students.
Recent years have seen intense criticism of university-based education. Calls for a “back to basics” education with training being based in hospitals not only ignore the reality of modern healthcare, but also fail to recognise that much of nurses’ education does occur in hospitals. So if we want to diagnose the problem and prescribe a solution, the failure of some hospitals to invest in the nursing workforce is a better place to start. Reducing our investment in educating nurses and encouraging the employment of less well educated practitioners flies in the face of the evidence.
We should be intolerant of inequalities in access to nursing and set national standards for education that focus not just on strength in numbers, but the capability of the workforce through education too. Investing in staffing and education holds the promise of a double dividend, which can only be good news for patients, nurses and the healthcare system as a whole.
Anne Marie Rafferty is professor of nursing policy and director of academic outreach at King’s College London; Peter Griffiths is Chair of health services research a the University of Southampton