Monday, 3 August 2015

Nurses: (+) training (-) workloads = (-) mortality

A few months ago, Mireia Subirana, Director of Care at "Consorci Hospitalari de Vic" explained in a post the results of her doctoral thesis that can be summarized as: "more nurses and more training (in hospital wards) was associated with better clinical outcomes". Following this thread, The Lancet has just published the results of a retrospective observational study that has explored whether the nurses training levels and workload ratios could influence the mortality of patients admitted for medium complexity scheduled surgery.

It’s an important work undertaken in 300 hospitals in 9 European countries by surveying 26.516 nurses and analysing 422.730 hospitalization surgical episodes. Despite the expected methodological difficulties of a project of this nature, it can be considered as a rigorous study.

The attached table shows, in the first column, the average number of patients per nurse in the hospital wards of each participating country. To avoid bias, the data has been collected by directly asking the nurses how many companions shared the last turn with them. Note that the 16 Spanish hospitals involved show the higher workload, with an average of 12.7 patients per nurse and a range going from 9.5 to 17.9; while, at the other extreme we can see Norway with an average of 5.2 and Ireland, with 6.9; figures highlighting a logical half the load of the Spanish nurses. The third column shows the average educational level of the surveyed nurses, the fact that nurses needed bachelor's degree in order to pursue the graduation being measured as a variable. In this variable, Spain and Norway top the rankings with 100% of registered nurses - baccalaureate included, while at the other extreme we find Switzerland with 10% and England with 28%.

Study Results

The study's authors made a very didactic summary of the undertaken statistical work:

When the number of patients rises by one in the ratio of nurses’ workload per hospital wards, the probability that a patient undergoing surgery die within 30 days is increased by 7%.

When the proportion of nurses with undergraduate education (including baccalaureate) rises by 10% in hospital wards, the probability that a patient undergoing surgery die within 30 days is reduced by 7%.

Despite being a relevant study, its limitations are obvious. Only scheduled surgical patients were included (43 types of interventions), the measured results are limited to mortality, etc. But what I like to emphasize is that this is another step in a line of research that is showing a strong association between clinical outcomes and nurses’ enrolment and training.

If you have time, take advantage of the link to the post of Mireia Subirana to see the features, that according to McClure, lead to a "magnet hospital", which are those centres that, in a context of lack of nurses, are able to attract (or retain) the best professionals with a clear impact on clinical outcomes.

Jordi Varela

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