Health Policy$ense

A ‘Quality Storm’ Brewing around NHS Nurses

44% Report Burnout; 66% Say They Don't Have Time to Comfort Patients

It seems that nurses are getting a lot of bad press in England lately, coming under fire recently for being “uncaring.” In an article published in Nursing Standard, Linda Aiken of Penn’s School of Nursing contends that this erosion of public trust is the result of high workloads and low investment in nursing education, rather than any attitudes held by English nurses.

Aiken should know. She led a large study of effective nursing practice known as the Registered Nurses Forecasting (RN4CAST) study, in which she could compare nurses’ reports on conditions of practice in NHS hospitals with nurses’ experiences in 11 other European countries. English nurses reported much higher levels of burnout, less adequate staffing and resources, and much poorer work environments than their European colleagues:

nursing standards

Forty-four percent of NHS nurses reported burnout, and nearly two-thirds said that that they do not have time to comfort and talk with patients, which is consistent with higher workloads in NHS hospitals. The survey found no evidence of negative attitudes among nurses toward their patients, leading Aiken to instead conclude that excessive workload and inadequate skill mix may be behind patients’ perceptions that they aren’t being properly cared for. She writes:

Linda Aiken
Linda Aiken-led study: For every additional surgical patient added to a nurse's workload, there was a 7% increase in deaths.

Instead of blaming nurses and expecting care to improve, it may be more productive to consider complaints about nurses as early warning signs that the quality of health care is being eroded, and then consider how to avert the ‘quality storm’.

In a recently published Lancet article, Aiken and colleagues tied these data on nurse workload and education to outcomes among patients who underwent common general, vascular, or orthopedic surgery in nine European hospitals. She found that for every additional patient added to a nurse’s workload, there was a 7% increase in deaths among surgical patients. Additionally, the study found that for every 10% increase in nurses with a bachelor’s degree, mortality was reduced by 7%.

Preventable deaths
To translate, Aiken and colleagues estimate that more than 3,500 hospital deaths across the nine countries might be prevented every year by improving nurse staffing and education.

The idea that a better-educated nursing staff can improve hospital outcomes is not a new one – but is an idea that has not yet gained traction in England. Aiken previously drew attention to that link in an analysis of discharge data and a survey of Pennsylvania nurses last year. Likewise, in 2011, the Institute of Medicine released a report titled "The Future of Nursing," which recommended that the U.S. bring the proportion of bachelors-degree educated nurses up to 80% by 2020.

And hospitals in the US could reap the monetary benefits of a more highly educated nursing staff as well. Aiken writes:

[E]ach US$1 spent on improvements to nurse staffing was estimated to return a minimum of $0.75 economic benefit to the investing hospital, not counting intangible benefits. Furthermore, a move from less qualified licensed vocational nurse hours to qualified professional nurse hours is estimated to save lives and money. Improved nurse staffing in US hospitals is associated with significantly reduced readmission rates, which is compelling in view of financial penalties in 2013 to 2225 hospitals for excessive readmissions.