Ratios save lives

An international study has shown that patients suffer when nurses are forced to work without safe staffing ratios.

Increasing the workload of nurses produces worse clinical outcomes for patients, including higher mortality following surgery.

This has been proved by the largest-ever international study of the relationship between nurse staffing levels and the quality of health care, which examined health outcomes in 30 countries on four continents.

The European component of the study, covering 617 hospitals, found that deaths following common surgical procedures were significantly lower in hospitals with fewer patients per nurse.

Every patient added to a nurse’s workload was associated with a 7 per cent increase in hospital deaths following common surgery.

These results add weight to the NSWNMA’s campaign to extend ratios to health services that were not included when the Association won mandatory ratios for many units of metropolitan and rural hospitals in 2011.

The results also validate the deep concern of nurses in New South Wales for their patients’ safety due to understaffing, and underline the importance of the Association’s decision to campaign for mandatory ratios.

The research, published in The Lancet*, was led by Dr Linda Aiken, professor of nursing and head of the Center for Health Outcomes and Policy Research at the University of Pennsylvania.

Dr Aiken, who is internationally renowned for her work on the relationship between the health care workforce and the quality of health care, spoke at a recent Queensland Nurses’ Union (QNU) symposium on Keeping Patients Safe, held in Brisbane.

Dr Aiken said the research also showed the greater the number of bachelor- educated nurses, the lower the number of patient deaths.

Among the findings:

  • Every one patient added to a nurse’s workload is associated with a 7 per cent increase in deaths following common surgery.
  • Every 10 per cent increase in university-educated nurses is associated with 7 per cent lower mortality.
  • If all hospitals in nine European countries studied had at least 60 per cent university-educated nurses, with no more than six patients each, more than 3500 deaths a year might be prevented.

The study found that other adverse consequences of poor nurse-to-patient ratios included more complications following surgery and a reduced likelihood of elderly patients returning to community living.

The European research covered nations as diverse as England, Spain, Poland, Germany, Greece and Switzerland. Despite their organisational and financial differences, in-hospital general surgery mortality varied more within countries than between countries.

The same phenomenon is revealed in a related study of all 850 hospitals in four large states of the USA – Pennsylvania, California, New Jersey and Florida – which account for a quarter of all US hospital admissions.

Dr Aiken told the QNU symposium there was “huge variation” in mortality rates between hospitals within each country.

“There is a seven-fold difference in mortality following common surgical procedures across nine countries in Europe. In the US it is a 12-fold difference.

“Even in England under the National Health Service – a ‘standardised product’ – you have a seven-fold difference in mortality after common surgical procedures.

“The question is not why is there a difference between mortality in different countries, but why do we have such a big difference in mortality within each country?

“The difference in nurse-to-patient ratios is a very big factor in explaining why. Nurse staffing levels were dramatically different between these hospitals and more nurses means lower mortality.”

In English hospitals, for example, nurse-to-patient average workloads ranged from 1:5.1 to 1:10.7.

“Even in countries that report they have ratios, we find that there is tremendous variation in the actual operation of those ratios, so this is why we find a relationship between difference in mortality and difference in nurse staffing.

“When you start telling the public there is a seven-fold difference in the likelihood they could die, you really get their attention on nurse numbers.’’

Dr Aiken said her team was getting similar results from surveys in Asian, African and South American hospitals.

She said while Australia was not included in her studies, “I’m willing to bet you will have the same variation in staffing and differences in mortality that we find in the 30 other countries.”

That was because in all countries studied, “… despite different systems, financing, resources in a country, every one patient increase in a nurse’s workload is associated with a 7 per cent increase in mortality.

“This is after we take into account all the other possible explanations for mortality, so this is the real direct impact of nurses on patient outcomes.”