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Study Finds Employment of More Nurse Assistants in Hospitals Is Associated with More Deaths and Lower Quality Care

Hospitals that employ more nurse assistants relative to the number of professionally qualified nurses have higher mortality rates, lower patient satisfaction, and poorer quality and safety of care, according to a new European study published today in the leading scientific journal BMJ Quality and Safety.

This study highlights the risks to patient safety and quality in hospitals that employ a greater proportion of lower skilled caregivers, say the lead study authors from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing (Penn Nursing). The article, ‘Nursing Skill Mix in European Hospitals: Cross-sectional Study of the Association with Mortality, Patient Ratings, and Quality of Care,’ is available here through open access.

The authors note that the study’s findings in Europe closely mirror those from the United States and Canada where research has consistently shown that patients’ lives and money could be saved by moving to a hospital nursing skill mix with a higher proportion of registered nurses (RNs). Costs are lower because good professional nurse staffing is associated with fewer costs incurred by patient complications.

This is the largest study to date of the outcomes of variations in nursing skill mix in European hospitals and finds:

  • The proportion of professional nurses among all nursing personnel at the hospital bedside averages 66 percent in European hospitals but varies across hospitals from a high of 87 percent professional nurses to a low of 41 percent.
  • The greater the proportion of professional nurses at the hospital bedside, the lower the mortality, the better the quality and safety of care, and the more likely that patients will express satisfaction with their care.
  • In European hospitals, where an average of six nursing personnel (four of whom are professional nurses) care for 25 patients, replacing one professional nurse with a lower-qualified nursing assistant is associated with a 21 percent increase in mortality and a 16 percent decrease in the likelihood that patients report being satisfied with their care.
  • Giving professional nurses more clinical assistants does not improve patient outcomes or reduce nurse burnout, job dissatisfaction, and intent to leave clinical care.
  • The key to improving care and retaining enough professional nurses at the bedside is to maintain safe professional nurse staffing levels in hospitals.

 A total of 242 representative hospitals were studied in Belgium, England, Finland, Ireland, Spain, and Switzerland. These countries are a subset of the 12 countries included in the large EU-funded RN4CAST study on the impact of nursing on quality of care in European hospitals selected because of the availability of independent data on mortality and patient satisfaction among hospitalized patients. The outcomes of 275,519 patients undergoing general surgery were reviewed. Some 18,828 patients rated their hospital care experience and 13,077 nurses practicing in the study hospitals reported on staffing levels and quality and safety of care.

“The contention of some leaders in health care that fewer highly skilled professional nurses in hospitals supported by lower skilled, lower waged workers is safe and cost effective is not supported by this study,” says lead author Linda Aiken, PhD, RN, Director of Penn Nursing’s Center for Health Outcomes and Policy Research. “This research is consistent with a growing body of research showing that sufficient numbers of professional nurses providing direct care to hospitalized patients produces the best outcomes and avoids costly adverse care outcomes.”

“This is a very timely study because the NHS in England has announced its intention to train a new category of worker called ‘nursing associates’ who have limited qualifications and to use a measure that ignores the distinctions between registered nurses and untrained assistants when comparing staffing levels between hospitals and wards,” added co-author, Peter Griffiths, Chair of Health Services Research at the University of Southampton. “England has one of the lowest percentages among European countries of professional nurses at the bedside already. Our study suggests that the NHS needs to focus on achieving safe registered nurse staffing levels as a means to achieve better outcomes including improving patients’ satisfaction with their care.”

Co-author, Anne Marie Rafferty, DPhil (Oxon) RN, from the Florence Nightingale Faculty of Nursing and Midwifery, King’s College London adds, “Our study finds that high professional nurse burnout and job dissatisfaction in hospital nursing practice is not alleviated by adding lower skilled workers. This fuels staff turnover and poses a significant threat to the sustainability of the NHS. Our results suggest that achieving safe professional nurse staffing is a more efficient and productive way to retain more nurses at the hospital bedside.”

“The findings are highly relevant to Europe with its difficulties in recovering from the economic crisis and facing continuous austerity measures in health care,” said Walter Sermeus, co-author at KU Leuven and European coordinator of the RN4CAST study.

The RN4CAST study was funded by European Union’s Seventh Framework Program (223468) and the National Institute of Nursing Research, National Institutes of Health (NR014855).