Effects of Nursing WorkEnvironments and Staffing on Patient Outcomes Linda H. Aiken www.rn4cast.eu
RN4CAST: EU-Funded Study of Hospital Nurse Workforce 34,000 nurses 12 Europe 488 hospitals 2,087 nursing units 11,318 patients countries surveyed Patient outcomes from hundreds of thousands ……… Ensuring an effective workforce for an aging population 2
Goals of Health System Reforms• Achieving the best possible patient outcomes with available resources: What are the most promising strategies for policy and management consideration? – Patient satisfaction – Safety of Care – Reduce preventable adverse patient outcomes including unnecessary deaths• Nurse retention is critical to preventing nursing shortages now and in the future: What are the most important factors influencing nurse retention?
Hospital Patient Satisfaction In percent Recommend Rate hospital 9 or 10 Hospital Belgium 47 60 Switzerland 60 78 Germany 48 66 Spain 35 56 Finland 61 67 Greece 42 53 Ireland 61 74 Poland 55 57 United States 59 64
What do we know about the factorsthat influence patient satisfaction?
Nursing Care Left Undone Because of Lack of Time Country% Reporting the England Norway Spain SwitzerlandFollowing Tasks LeftUndone Administer medications on time 22 15 8 15 Treatments and procedures 11 7 4 3 Skin care 21 30 24 16 Educating patients and family 52 24 50 30 Comfort/talk with patients 66 38 39 51
% Nurses reporting absence of positive working relationships between physicians and nurses50 444540 37 34 3435 303025 23 22 21 192015 % nurses 11 10 11 11 reporting10 5 0
Good Nurse Work Environments are Associated with Higher Patient Satisfaction– Patients are 16% more likely to give hospitals the best rating if nurse work environments are good– Patients are 20% more likely to recommend the hospital if nurse work environments are good
Hospital Safety Grade is Higher in Hospitals with Better Work Environments Every Country by Nurse Work Environment Belgium England Finland Germany Excellent Good AcceptablePatient Safety Grade Fair Ireland Netherlands Norway Poland Excellent Good Acceptable Fair Spain Sweden Switzerland United States Excellent Good Acceptable Fair 2 2.5 3 3.5 2 2.5 3 3.5 2 2.5 3 3.5 2 2.5 3 3.5 Nurse Work Environment
RN4CAST Hospital Mortality Study• There is a 66% difference between hospital mortality rates for general surgery patients across 9 European countries for which we have comparable mortality data including Spain.• We hypothesize that better hospital work environments, higher percentages of bachelor’s degree nurses, and better nurse staffing explain lower patient mortality
Higher proportion of nurses withbachelor’s degrees associated with lower hospital mortality in previous studies• U.S.: Each 10% increase hospital staff nurses with bachelor’s = 5% lower mortality & failure to rescue, JAMA 2003 and Medical Care 2011• Result has been replicated in Canada, Belgium, China• Is bachelor’s education associated with mortality in Europe more broadly?
RN4CAST Mortality Findings• Work environments, % bachelor’s degrees, and patient to nurse ratios are significantly related to hospital mortality rates for general surgery• Hospitals with good nurse work environments are significantly more likely to have lower mortality• Every 10% increase in bachelor’s nurses is associated with a 7% reduction in the odds of patients dying• Each 1 patient increase in nurses’ workloads (patient to nurse ratio) is associated with a 7% increase in the odds of patients dying
Work Environments and Nurse Retention• Nurses in hospitals with good nurse work environments are one-third less likely than nurses in hospitals with fair/poor work environments to – Experience high job burnout – Be dissatisfied with their jobs – Intend to leave their jobs
Hospitals with Better Work Environments: Lower Nurse Burnout Every Country Worse Best
Implications for Policy and Practice• Spain’s decision to move to all bachelor’s degree nurses was an important step with positive effects on hospital care quality.• Improving hospital work environments is a relatively low cost intervention which could result in better patient outcomes and improved nurse retention now and in future.• When economic conditions permit, reducing patient to nurse ratios and improving nursing skill mix may help improve patient satisfaction and further reduce preventable adverse patient outcomes.