An “inconvenient truth” about nurse staffing cuts

We have heard lots about transforming the in-hospital workforce recently, Change is inevitable – and contentious – but I think one thing we can all agree on is that change has to be for the right reasons, and certainly must be informed by evidence.  That’s what I want to talk about today: evidence.

An article came across my desk last week – a large European study published in the prestigious medical journal The Lancet in late February of this year (This is a journal renowned for publishing what scientists call “big science” in the world of health and medicine).

In this study, led by nurse scientist Linda Aitken, the authors aimed to assess whether differences in patient-to-nurse workloads and nurses’ educational qualifications in nine European countries were associated with variation in hospital mortality after common surgical procedures. This was a robust and sophisticated study, examining and controlling for a multiple of variables in the analysis of discharge data for over 400,000 patients. The study also included data from surveys of more than 26,000 nurses practising in the study hospitals, in order to measure nurse staffing and nurse education. Yup, this is BIG science.

What did they find? That 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%. Put another way, 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.

This is powerful evidence, and important to consider as we move forward in Alberta. The authors note that the finding that improved hospital nurse staffing is associated with decreased risk of mortality might be inconvenient in the present difficult financial context in Europe – but they also argue that it is inconvenient only if decision-makers take a short-sighted view.

It is evidence like this that must be on the table as we consider how to maximize the RN contribution in our acute care hospitals. In fact, maximizing the RN contribution has to be seen as an investment in better outcomes for patients.  It also tells us that we had better pay close attention to patient outcomes as we implement skill mix changes in the system. I do not think that the findings diminish the importance of collaborative teamwork with other nursing professionals–indeed, if adding other care providers can ensure that RNs are able to do what they are educated to do for patients then we could be on the right track… but if the endgame is to reduce RNs in order to save money, we would do well to consider the overarching conclusions of this study Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths.”

An inconvenient truth? Maybe. But it is one we ignore at the public’s peril.


- Shannon