Correspondence
I read with interest Linda Aiken and colleagues’ study (May 24, p 1824),1 that found improved nurse staffing and education was associated with a decreased risk of mortality in patients undergoing general, orthopaedic, or vascular surgery in nine European countries. This study raises a number of interesting points. There seems to be great disparity in the level of formal education among nurses in Europe. As evidenced by the present study, this heterogeneity might contribute to increased patient mortality. A bachelors degree in medicine and surgery is internationally recognised as a compulsory requirement for all doctors. Given that nurses spend arguably more time in the acute monitoring and management of patients than other health professionals,2,3 it is somewhat surprising that similar basic formal qualifications are yet to be universally implemented in nursing. The authors assessed only one outcome, mortality. Future studies should also consider the effect of iatrogenic factors such as medication dispensing errors and patient complications such as hospital-acquired infection. Although the present study is the largest to date, results should be interpreted with caution given that in the survey, from which nurse staffing and education measures were derived, response rate was below 50% in some countries. Furthermore, as with any survey, a potential for response bias exists. Additionally, in research drawing on administrative patient outcomes data, a potential for variation in consistency of diagnostic coding across hospitals and between different countries exists.4 I declare no competing interests.
Rele Ologunde [email protected]
www.thelancet.com Vol 384 September 6, 2014
Faculty of Medicine, Imperial College London, London SW7 2AZ, UK 1
2
3
4
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Westbrook JI, Duffield C, Li L, Creswick NJ. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses’ patterns of task time distribution and interactions with health professionals. BMC Health Serv Res 2011; 11: 319. Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Austr 2008; 188: 506–09. Iezzoni LI. Risk adjustment for measuring healthcare outcomes, 2nd edn. Chicago: Health Administration Press, 1997.
Linda Aiken and colleagues assessed the effects of two nursing factors (staffing and education) on mortality for 422 730 patients who underwent common surgeries.1 Although Aiken and colleagues did not clearly refer to the turnover rate of the nurses, it is known that turnover of health-care staff negatively but significantly influences the costs.2 In a previous report,3 reasonable workloads and nurse–patient ratios were manageable to promote retention among all generations of nurses in the acute care hospital workforce. Another report4 showed that the turnover rate of the nurses with a bachelor degree was less than that of the nurses without a bachelor degree. Therefore, data and analysis of turnover rate will be important information. I declare no competing interests.
Masako Sugihara [email protected] Department of Neuropsychiatry, Keio University School of Medicine, 160-8582 Tokyo, Japan 1
2
3
4
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Waldman JD, Kelly F, Arora S, Smith HL, et al. The shocking cost of turnover in health care. Health Care Manage Rev 2004; 29: 2–7. Tourangeau AE, Thomson H, Cummings G, et al. Generation-specific incentives and disincentives for nurses to remain employed in acute care hospitals. J Nurs Manag 2013; 21: 473–82. Suzuki E, Itomine I, Kanoya Y, Katsuki T, Horii S, Sato C. Factors affecting rapid turnover of novice nurses in university hospitals. J Occup Health 2006; 48: 49–61.
Authors’ reply Hospital mortality varies substantially within European countries. Our paper1 provides scientific evidence that failure to standardise nursing education at the bachelor’s level puts patients at higher risk of dying after common surgeries. We concur with Rele Ologunde that it is alarming that formal bachelor’s qualifications are yet to be universally implemented in nursing. We used in our study state-of-thescience techniques using existing administrative data on patient outcomes. Others have shown2 that routinely collected administrative data in Europe predict risk of hospital death with discrimination similar to that obtained from clinical data. Mortality is the one standardised outcome across European countries in administrative data. In the USA where performance reporting on standardised measures is required, nurse resources are associated with a wide range of outcomes including readmissions, poor glycaemic control, hospital acquired infections, falls, and patient safety indicators.3,4 Concerning potential non-response bias, response at the hospital level is a priority in research on hospital performance. In RN4CAST, most hospitals selected through stratified sampling methods used to ensure representativeness agreed to participate. Nurses in hospitals were informants through surveys about their own characteristics such as educational qualifications and how many patients they cared for on their last shift, measures that are reasonably objective. Our overall nurse response rate across nine countries was 62%, acceptable by current standards in health services research. In a similarly designed study in the USA, we compared survey respondents and non-respondents and found no informative non-response bias.5 Previously published research5 from RN4CAST using a different independent measure of patient outcome (ie, patient satisfaction) produced a similar finding of the
Belmonte/BSIP/Science Photo Library
Staffing and education of nurses and hospital mortality in Europe
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
851
I read with interest Linda Aiken and colleagues’ study (May 24, p 1824),1 that found improved nurse staffing and education was associated with a decreased risk of mortality in patients undergoing general, orthopaedic, or vascular surgery in nine European countries. This study raises a number of interesting points. There seems to be great disparity in the level of formal education among nurses in Europe. As evidenced by the present study, this heterogeneity might contribute to increased patient mortality. A bachelors degree in medicine and surgery is internationally recognised as a compulsory requirement for all doctors. Given that nurses spend arguably more time in the acute monitoring and management of patients than other health professionals,2,3 it is somewhat surprising that similar basic formal qualifications are yet to be universally implemented in nursing. The authors assessed only one outcome, mortality. Future studies should also consider the effect of iatrogenic factors such as medication dispensing errors and patient complications such as hospital-acquired infection. Although the present study is the largest to date, results should be interpreted with caution given that in the survey, from which nurse staffing and education measures were derived, response rate was below 50% in some countries. Furthermore, as with any survey, a potential for response bias exists. Additionally, in research drawing on administrative patient outcomes data, a potential for variation in consistency of diagnostic coding across hospitals and between different countries exists.4 I declare no competing interests.
Rele Ologunde [email protected]
www.thelancet.com Vol 384 September 6, 2014
Faculty of Medicine, Imperial College London, London SW7 2AZ, UK 1
2
3
4
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Westbrook JI, Duffield C, Li L, Creswick NJ. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses’ patterns of task time distribution and interactions with health professionals. BMC Health Serv Res 2011; 11: 319. Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Austr 2008; 188: 506–09. Iezzoni LI. Risk adjustment for measuring healthcare outcomes, 2nd edn. Chicago: Health Administration Press, 1997.
Linda Aiken and colleagues assessed the effects of two nursing factors (staffing and education) on mortality for 422 730 patients who underwent common surgeries.1 Although Aiken and colleagues did not clearly refer to the turnover rate of the nurses, it is known that turnover of health-care staff negatively but significantly influences the costs.2 In a previous report,3 reasonable workloads and nurse–patient ratios were manageable to promote retention among all generations of nurses in the acute care hospital workforce. Another report4 showed that the turnover rate of the nurses with a bachelor degree was less than that of the nurses without a bachelor degree. Therefore, data and analysis of turnover rate will be important information. I declare no competing interests.
Masako Sugihara [email protected] Department of Neuropsychiatry, Keio University School of Medicine, 160-8582 Tokyo, Japan 1
2
3
4
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Waldman JD, Kelly F, Arora S, Smith HL, et al. The shocking cost of turnover in health care. Health Care Manage Rev 2004; 29: 2–7. Tourangeau AE, Thomson H, Cummings G, et al. Generation-specific incentives and disincentives for nurses to remain employed in acute care hospitals. J Nurs Manag 2013; 21: 473–82. Suzuki E, Itomine I, Kanoya Y, Katsuki T, Horii S, Sato C. Factors affecting rapid turnover of novice nurses in university hospitals. J Occup Health 2006; 48: 49–61.
Authors’ reply Hospital mortality varies substantially within European countries. Our paper1 provides scientific evidence that failure to standardise nursing education at the bachelor’s level puts patients at higher risk of dying after common surgeries. We concur with Rele Ologunde that it is alarming that formal bachelor’s qualifications are yet to be universally implemented in nursing. We used in our study state-of-thescience techniques using existing administrative data on patient outcomes. Others have shown2 that routinely collected administrative data in Europe predict risk of hospital death with discrimination similar to that obtained from clinical data. Mortality is the one standardised outcome across European countries in administrative data. In the USA where performance reporting on standardised measures is required, nurse resources are associated with a wide range of outcomes including readmissions, poor glycaemic control, hospital acquired infections, falls, and patient safety indicators.3,4 Concerning potential non-response bias, response at the hospital level is a priority in research on hospital performance. In RN4CAST, most hospitals selected through stratified sampling methods used to ensure representativeness agreed to participate. Nurses in hospitals were informants through surveys about their own characteristics such as educational qualifications and how many patients they cared for on their last shift, measures that are reasonably objective. Our overall nurse response rate across nine countries was 62%, acceptable by current standards in health services research. In a similarly designed study in the USA, we compared survey respondents and non-respondents and found no informative non-response bias.5 Previously published research5 from RN4CAST using a different independent measure of patient outcome (ie, patient satisfaction) produced a similar finding of the
Belmonte/BSIP/Science Photo Library
Staffing and education of nurses and hospital mortality in Europe
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
851
