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      Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States

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          Abstract

          Objective To determine whether hospitals with a good organisation of care (such as improved nurse staffing and work environments) can affect patient care and nurse workforce stability in European countries.

          Design Cross sectional surveys of patients and nurses.

          Setting Nurses were surveyed in general acute care hospitals (488 in 12 European countries; 617 in the United States); patients were surveyed in 210 European hospitals and 430 US hospitals.

          Participants 33 659 nurses and 11 318 patients in Europe; 27 509 nurses and more than 120 000 patients in the US.

          Main outcome measures Nurse outcomes (hospital staffing, work environments, burnout, dissatisfaction, intention to leave job in the next year, patient safety, quality of care), patient outcomes (satisfaction overall and with nursing care, willingness to recommend hospitals).

          Results The percentage of nurses reporting poor or fair quality of patient care varied substantially by country (from 11% (Ireland) to 47% (Greece)), as did rates for nurses who gave their hospital a poor or failing safety grade (4% (Switzerland) to 18% (Poland)). We found high rates of nurse burnout (10% (Netherlands) to 78% (Greece)), job dissatisfaction (11% (Netherlands) to 56% (Greece)), and intention to leave (14% (US) to 49% (Finland, Greece)). Patients’ high ratings of their hospitals also varied considerably (35% (Spain) to 61% (Finland, Ireland)), as did rates of patients willing to recommend their hospital (53% (Greece) to 78% (Switzerland)). Improved work environments and reduced ratios of patients to nurses were associated with increased care quality and patient satisfaction. In European hospitals, after adjusting for hospital and nurse characteristics, nurses with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval 0.51 to 0.61) and give their hospitals poor or failing grades on patient safety (0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds of nurses reporting poor or fair quality care (1.11, 1.07 to 1.15) and poor or failing safety grades (1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (1.16, 1.03 to 1.32) and recommend their hospitals (1.20, 1.05 to 1.37), whereas those with higher ratios of patients to nurses were less likely to rate them highly (0.94, 0.91 to 0.97) or recommend them (0.95, 0.91 to 0.98). Results were similar in the US. Nurses and patients agreed on which hospitals provided good care and could be recommended.

          Conclusions Deficits in hospital care quality were common in all countries. Improvement of hospital work environments might be a relatively low cost strategy to improve safety and quality in hospital care and to increase patient satisfaction.

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          Most cited references 10

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          The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis.

          To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol. Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86). Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.
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            Explaining differences in English hospital death rates using routinely collected data.

            To ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios. Weighted linear regression analysis of routinely collected data over four years, with hospital standardised mortality ratios as the dependent variable. England. Eight million discharges from NHS hospitals when the primary diagnosis was one of the diagnoses accounting for 80% of inpatient deaths. Hospital standardised mortality ratios and predictors of variations in these ratios. The four year crude death rates varied across hospitals from 3.4% to 13.6% (average for England 8.5%), and standardised hospital mortality ratios ranged from 53 to 137 (average for England 100). The percentage of cases that were emergency admissions (60% of total hospital admissions) was the best predictor of this variation in mortality, with the ratio of hospital doctors to beds and general practitioners to head of population the next best predictors. When analyses were restricted to emergency admissions (which covered 93% of all patient deaths analysed) number of doctors per bed was the best predictor. Analysis of hospital episode statistics reveals wide variation in standardised hospital mortality ratios in England. The percentage of total admissions classified as emergencies is the most powerful predictor of variation in mortality. The ratios of doctors to head of population served, both in hospital and in general practice, seem to be critical determinants of standardised hospital death rates; the higher these ratios, the lower the death rates in both cases.
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              Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records.

              Despite growing evidence in the US, little evidence has been available to evaluate whether internationally, hospitals in which nurses care for fewer patients have better outcomes in terms of patient survival and nurse retention. To examine the effects of hospital-wide nurse staffing levels (patient-to-nurse ratios) on patient mortality, failure to rescue (mortality risk for patients with complicated stays) and nurse job dissatisfaction, burnout and nurse-rated quality of care. Cross-sectional analysis combining nurse survey data with discharge abstracts. Nurses (N=3984) and general, orthopaedic, and vascular surgery patients (N=118752) in 30 English acute trusts. Patients and nurses in the quartile of hospitals with the most favourable staffing levels (the lowest patient-to-nurse ratios) had consistently better outcomes than those in hospitals with less favourable staffing. Patients in the hospitals with the highest patient to nurse ratios had 26% higher mortality (95% CI: 12-49%); the nurses in those hospitals were approximately twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals. Nurse staffing levels in NHS hospitals appear to have the same impact on patient outcomes and factors influencing nurse retention as have been found in the USA.
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                Author and article information

                Contributors
                Role: professor and director
                Role: professor and director
                Role: health services research expert
                Role: professor
                Role: professor and director
                Role: professor
                Role: research fellow
                Role: professor
                Role: professor
                Role: director
                Role: professor
                Role: professor
                Role: professor
                Role: professor
                Role: head of education
                Role: senior researcher
                Role: researcher
                Role: senior researcher
                Role: professor and director
                Role: assistant professor
                Journal
                BMJ
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1756-1833
                2012
                2012
                20 March 2012
                : 344
                Affiliations
                [1 ]Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA
                [2 ]Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
                [3 ]Department of Health Care Management, WHO Collaborating Centre for Health Systems, Research and Management, University of Technology Berlin, Berlin, Germany
                [4 ]Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
                [5 ]Florence Nightingale School of Nursing and Midwifery, King’s College London, London
                [6 ]School of Health Sciences, University of Southampton, Southampton, UK
                [7 ]National Spanish Research Unit, Instituto de Salud Carlos III, Ministry of Science and Innovation, Madrid, Spain
                [8 ]Medical Management Centre, LIME, Karolinska Institutet, Stockholm, Sweden
                [9 ]School of Nursing, Dublin City University, Dublin, Ireland
                [10 ]Department of Internal Diseases and Community Nursing, Faculty of Health Care, Jagiellonian University Collegium Medicum, Krakow, Poland
                [11 ]Department of Health Policy and Management, University of Eastern Finland, Kuopio, Finland
                [12 ]Institute of Nursing Science, University of Basel, Basel, Switzerland
                [13 ]IQ Healthcare, Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, Netherlands
                [14 ]Laboratory of Health Informatics, Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
                [15 ]Norwegian Knowledge Centre for the Health Services, Oslo, Norway
                [16 ]Population Studies Center, Department of Sociology, University of Pennsylvania, Philadelphia
                [17 ]Belgian Healthcare Knowledge Centre, Brussels, Belgium
                Author notes
                Correspondence to: L H Aiken laiken@ 123456nursing.upenn.edu
                Article
                aikl000694
                10.1136/bmj.e1717
                3308724
                22434089
                © Aiken et al 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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                Categories
                Research
                Patients
                Medical Error/ Patient Safety
                Quality Improvement

                Medicine

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