III Jornada Técnica de Investigación en Cuidados “Estrategias y prioridades en el ámbito de los Servicios de Salud”

1. Effects of Nursing Work
Environments and Staffing on
Patient Outcomes
Linda H. Aiken
www.rn4cast.eu

2. 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

3. 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?

4. 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

5. What do we know about the factors
that influence patient satisfaction?

6. Nurses and Patients Agree on
Good Hospitals
Belgium Switzerland Germany
% Patients Recommend Hospital
80
60
40
20
Spain Finland Greece
80
60
40
20
0 20 40 60
Ireland Poland
80
60
40
20
0 20 40 60 0 20 40 60
% Nurses Recommend Hospital

7. Nursing Care Left Undone
Because of Lack of Time
Country
% Reporting the England Norway Spain Switzerland
Following Tasks Left
Undone
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

8. % Nurses Reporting Poor/Fair
Hospital Work Environment
80 76
69
70
60 56 57
51 52 52 54 52
50 44 42
40 37
29
30
% nurses
20 reporting
10
0

9. % Nurses not confident management
will resolve problems
100
90 87 85 86
80 81 81
80 74 73 75
70 64 63
58 56
60
50
40
30 % reporting
20
10
0

10. % Nurses reporting absence of
positive working relationships
between physicians and nurses
50
44
45
40 37
34 34
35
30
30
25 23 22
21
19
20
15 % nurses
11 10 11 11 reporting
10
5
0

11. 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

12. Hospital Safety Grade is Higher in Hospitals with
Better Work Environments Every Country
by Nurse Work Environment
Belgium England Finland Germany
Excellent
Good
Acceptable
Patient 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

13. 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

14. % Bachelor’s Prepared Nurses
120
100 100
100
80
51 60 59
60 52
40 56 32
20 22
20 10
0
0

15. 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?

16. 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

17. 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

18. Hospitals with Better Work Environments:
Lower Nurse Burnout Every Country
Worse Best

19. 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.