Patients 'are safer with better-educated nurses'

Behind the Headlines

Wednesday February 26 2014

Patient to nurse ration appeared to influence short-term outcomes

Since 2013 all new NHS nurses must be educated to degree level

“Fewer nurses educated to degree level putting patients' lives at risk, study finds,” The Independent reports. A Europe-wide study suggests that nurse education and patient to nursing staff ratios may impact on patient outcomes.

As many European countries tighten their budgets, one obvious opportunity to save costs is to trim nursing staffing levels. But could this have a negative impact on patient safety?

Researchers found that an increase in a nurses’ workload by one patient was associated with a 7% increase in patient deaths. In addition, a better educated workforce was associated with fewer deaths, with every 10% increase in nurses with degrees associated with a 7% reduction in death rates.

This was a large, well-conducted study that involved close to a million patients in 300 hospitals across Europe and its findings will be of concern to policy makers and the public.

However, it is important to note that many factors can affect patient outcomes, such as the presence of senior medical staff at weekends and the quality of hospital management.

A final reassuring note is that in the UK, as of last year, all new entrants to nursing have to be educated to degree level.


Nurse staffing

One of the key measures of nurse staffing is the average patients to nurse ratio; how many patients an individual nurse is expected to care for.


This is how the countries studied measured up:

  • Norway 5.2 to 1
  • Ireland 6.9 to 1
  • Netherlands 7 to 1
  • Finland 7.6 to 1
  • Sweden 7.6 to 1
  • Switzerland 7.8 to 1
  • England 8.8 to 1
  • Belgium 10.8 to 1
  • Spain 12.7 to 1

Where did the story come from?

The study was carried out by researchers from the University of Pennsylvania in the US, Catholic University of Leuven in Belgium, University of Southampton, Berlin University of Technology in Germany, University of Athens in Greece, University of Eastern Finland,  Jagiellonian University in Poland, Institute of Health Carlos III in Spain, the University of London and the Institute of Nursing Science in Switzerland. It was funded by the European Union, the National Institute of Nursing Research and the National Institutes of Health in the US. 

The study was published in the peer-reviewed medical journal The Lancet.

It was covered fairly in the papers and news websites. And most media sources included the fact that as from last year, all new UK nurses will be educated to degree level. Though not surprisingly, the study was linked to concerns over staffing levels in the NHS.

The Department of Health replied to the implied criticism by pointing out that “nurse numbers are at their highest level ever since the NHS was founded in 1948”.


What kind of research was this?

This was an observational cross-sectional study.

This aim of the study was to assess whether differences in patient-nurse ratios and nurses’ educational qualifications were associated with differences in mortality rates. The researchers decided to focus on patients who had undergone common surgical procedures, such as an appendectomy (surgical removal of the appendix).

Cross-sectional studies look at all data at the same time, so they they cannot be used to see if one thing follows another. Though they are useful for showing up patterns or links in the data.

The researchers say that minimising hospital expenditure is an important policy objective in Europe, despite concerns about adverse outcomes for quality and safety of health care.

Nursing is a “soft target” because savings can be made quickly by reducing nurse staffing.

They argue that the consequences of “trying to do more with less” have been proved to be potentially dangerous in the recent Francis and Keogh reports in England. As both reports concluded inadequate nurse staffing contributed to preventable deaths.

Their study is designed to inform decision making about nursing and to guide workforce planning.


What did the research involve?

The researchers obtained data on 422,730 patients aged 50 years or older, with a hospital stay of at least two days, who underwent common surgical procedures. The data came from administrative sources at 300 hospitals in nine European countries – Belgium, England, Finland, Ireland, the Netherlands, Norway, Spain, Sweden and Switzerland.

Only patients for whom complete information was available were included, such as other illnesses, the type of surgery they had and their age. Researchers looked primarily at whether patients died in the hospital within 30 days of admission.

They also used data on nurse staffing and education from surveys of 26,516 bedside care professional nurses in the same hospitals.

This information came from a large, ongoing nursing workforce study being conducted in Europe.

The term nurse refers to fully qualified professional nurses and in most countries, all nurses providing direct patient care in random samples of adult medical and surgical wards were surveyed (in England all wards were sampled up to a maximum of 10). 

Nurse staffing for each hospital was calculated by dividing the number of patients by the number of nurses that each nurse reported were present on their ward on their last shift, and then averaging ratios across all nurse respondents in each hospital. Low ratios therefore suggested more favourable staffing.

They measured nurse education by calculating the percentage of all nurses in each hospital that reported that the highest academic qualification they had earned was a bachelor’s degree (a degree, in most cases, obtained at a university) or higher.

They obtained patient mortality data for postoperative patients discharged from the hospitals in the year nearest to the nurse survey for which data were available, which ranged between countries from 2007 to 2009.

Researchers used standard statistical methods to analyse associations between nurse staffing and nurses’ education, and 30 day inpatient mortality rates.

They adjusted their findings for other factors affecting patient mortality rates (confounders) such as type of hospital, type of surgery, and age of patient.


What were the basic results?

The researchers found that:

  • an increase in nurses’ workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1.068, 95% confidence interval 1.031-1.106)
  • every 10% increase in bachelor’s degree nurses was associated with a reduction in the likelihood of an inpatient dying by 7% (odds ratio 0.929, 95% confidence interval 0.886-0.973)

The researchers compared two hypothetical hospitals:

  • in the first hospital 60% of nurses had degrees and nurses cared for an average of six patients
  • in the second hospital only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients

Based on their findings, the mortality rate in the first hospital was almost 30% lower than the second hospital.


How did the researchers interpret the results?

The researchers say that nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on a degree education for nurses could reduce preventable hospital deaths.

In an accompanying press release, study author Linda H Aiken, Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, said: “Our results suggest that the assumption that hospital nurse staffing can be reduced to save money without adversely affecting patient outcomes may be foolish at best, and fatal at worst.

“Hospitals should take notice because when budgets are tight, cutting back on nurses is often the first step but one that can have disastrous consequences for patients.”



This was a large well-conducted study supporting what many people intuitively suspect: that lower nurse staffing levels result in poorer patient care and may be linked to higher mortality rates.

The findings on nurse education being associated with improved mortality rates are particularly interesting. In the UK, a university education is considered essential to provide nurses with the specialist skills and decision making needed in modern nursing.

It’s important to note that many factors can affect patient outcomes, such as the presence of senior medical staff at weekends and the quality of hospital management. 

As the authors point out, the study has limitations. It is possible that measures of nurse staffing across all shifts may be skewed by different ratios on night shifts. Its measure of education relied on each country’s varying definition of a bachelor’s degree. It is possible that although the authors adjusted their results for confounders, other unmeasured factors may have affected the results.

Also, death rates for patients were taken from the year that most closely matched the nurse survey year but these two data sources were not always aligned.

Finally, the data was cross-sectional, which means the study cannot show that low nurse staffing levels or nurse education directly cause higher death rates.

Nevertheless, this study has important implications for policy makers.

The NHS is always on the lookout for both women and men with the potential to become skilled nurses. Read more about training to become a nurse.

 Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Analysis by Bazian

Edited by NHS Choices


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