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III Jornada Técnica de Investigación en Cuidados “Estrategias y prioridades en el ámbito de los Servicios de Salud”
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Effects of Nursing Work Environments and Staffing on
Patient Outcomes
Linda H. Aiken
www.rn4cast.eu
2 Ensuring an effective workforce for an aging population
… … …
12 Europe countries
488 hospitals 2,087 nursing units 34,000 nurses
11,318 patients surveyed
RN4CAST: EU-Funded Study of Hospital Nurse Workforce
Patient outcomes from hundreds of thousands
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?
Rate hospital 9 or 10
Recommend 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
Hospital Patient Satisfaction In percent
What do we know about the factors that influence patient satisfaction?
20 40 60 80
20 40 60 80
20 40 60 80
0 20 40 60
0 20 40 60 0 20 40 60
Belgium Switzerland Germany
Spain Finland Greece
Ireland Poland
Nurses and Patients Agree on
Good Hospitals
% P
ati
en
ts R
ec
om
me
nd
Ho
sp
ita
l
% Nurses Recommend Hospital
Nursing Care Left Undone Because of Lack of Time
Country
% Reporting the Following Tasks Left Undone
England Norway Spain Switzerland
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 Poor/Fair Hospital Work Environment
51 56
52 52
69
54
44
29
76
52 57
37 42
0
10
20
30
40
50
60
70
80
% nurses reporting
% Nurses not confident management will resolve problems
80
64
81
58
87
63
81 74
85 86
73 75
56
0
10
20
30
40
50
60
70
80
90
100
% reporting
% Nurses reporting absence of positive working relationships between physicians and nurses
30
11
21
37 34
23 19
10
44
34
11 11
22
0
5
10
15
20
25
30
35
40
45
50
% nurses reporting
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
Fair
Acceptable
Good
Excellent
Fair
Acceptable
Good
Excellent
Fair
Acceptable
Good
Excellent
2 2.5 3 3.5 2 2.5 3 3.5 2 2.5 3 3.5 2 2.5 3 3.5
Belgium England Finland Germany
Ireland Netherlands Norway Poland
Spain Sweden Switzerland United States
Nurse Work Environment
Pa
tie
nt
Sa
fety
Gra
de
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
% Bachelor’s Prepared Nurses
51
56
52
0
20
60
32
100
22
100
59
10
0
20
40
60
80
100
120
Higher proportion of nurses with bachelor’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
Best Worse
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.
