M. Jackson Group Update – March 2014 – Nursing Levels and Patient Mortality

This month’s article is taken from Ken Pope’s listserv. I am very proud of the Psychiatric Nurses who have recently come forward to say that they simply are not safe, particularly in facilities such as Maples. It was brave of them and admirable of CBC to light a big enough fire under this to get this moving in the BC legislature. The article is as follows:
*Lancet* has scheduled an article for publication in a future issue of the journal: “Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.”

The authors are Prof Linda H Aiken PhD a Corresponding AuthorEmail Address, Douglas M Sloane PhD a, Luk Bruyneel MS b, Koen Van den Heede PhD b, Prof Peter Griffiths PhD c, Prof Reinhard Busse MD d, Marianna Diomidous PhD e, Prof Juha Kinnunen PhD f, Prof Maria Kózka PhD g, Prof Emmanuel Lesaffre PhD h, Matthew D McHugh PhD a, M T Moreno-Casbas PhD i, Prof Anne Marie Rafferty PhD j, Rene Schwendimann PhD k, Prof P Anne Scott PhD l, Prof Carol Tishelman PhD m, Theo van Achterberg PhD n, & Prof Walter Sermeus PhD b, for the RN4CAST consortium.

PLEASE NOTE: As usual, I’ll include both the author’s email address (for requesting electronic reprints) and a link to the complete article at the end below.

Here’s how the article starts:

[begin excerpt]

Constraint of health expenditure growth is an important policy objective in Europe despite concerns about adverse outcomes for quality and safety of health care.1, 2 Hospitals are a target for spending reductions. Health-system reforms have shifted resources to provide more care in community settings while shortening hospital length of stay and reducing inpatient beds, resulting in increased care intensity for inpatients. The possible combination of fewer trained staff in hospitals and intensive patient interventions raises concerns about whether quality of care might worsen. Findings of the European Surgical Outcomes Study3 across 28 countries recently showed higher than expected hospital surgical mortality and substantial between country variation in hospital outcomes.

Nursing is a so-called soft target because savings can be made quickly by reduction of nurse staffing whereas savings through improved efficiency are difficult to achieve. The consequences of trying to do more with less are shown in England’s Francis Report,4 which discusses how nurses were criticised for failing to prevent poor care after nurse staffing was reduced to meet financial targets. Similarly, results of the Keogh review5 of 14 hospital trusts in England showed that inadequate nurse staffing was an important factor in persistently high mortality rates. Austerity measures in Ireland and Spain have been described as adversely affecting hospital staffing too.6, 7

[end excerpt]

Another excerpt: “An increase in a nurses’ workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7%…, and every 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7%…. These associations imply that patients in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients.”

Here’s how the Discussion section starts: “Our findings shows that an increase in nurses’ workload increases the likelihood of inpatient hospital deaths, and an increase in nurses with a bachelor’s degree is associated with a decrease in inpatient hospital deaths (panel). Findings of the RN4CAST study showed more variation in hospital mortality after common surgical procedures in European hospitals than is generally understood. Variation in hospital mortality is associated with differences in nurse staffing levels and educational qualifications. Hospitals in which nurses cared for fewer patients each and a higher proportion had bachelor’s degrees had significantly lower mortality than hospitals in which nurses cared for more patients and fewer had bachelor’s degrees. These findings are similar to those of studies of surgical patients in US and Canadian hospitals in which similar measures and protocols were used.14, 15”

Here’s how the article ends: “In summary, educational qualifications of nurses and patient-to-nurse staffing ratios seem to have a role in the outcomes of hospital patients in Europe. Previous findings from RN4CAST show that patients are more likely to express satisfaction with hospital care when nurses care for fewer patients each.24 To add to these findings, our data suggest that evidence-based investments in nursing are associated with reduction in hospital deaths.”

Reprint requests: <laiken@nursing.upenn.edu>

The article is online at:

Ken Pope


“Whenever people say ‘We mustn’t be sentimental,’ you can take it they are about to do something cruel. And if they add ‘We must be realistic,’ they mean they are going to make money out of it.”
–Brigid Brophy (1929-1995)

Take care,


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