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Lancet. 2014 May 24;383(9931):1824-30. doi: 10.1016/S0140-6736(13)62631-8. Epub 2014 Feb 26.

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.

Author information

Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA. Electronic address:
Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium.
Faculty of Health Sciences, University of Southampton, Southampton, UK.
Department of Health Care Management, WHO Collaborating Centre for Health Systems, Research and Management, Berlin University of Technology, Berlin, Germany.
Faculty of Nursing, University of Athens, Athens, Greece.
Department of Health Policy and Management, University of Eastern Finland, Kuopio, Finland.
Institute of Nursing and Midwifery, Faculty of Health Science, Jagiellonian University Collegium Medicum, Krakow, Poland.
Leuven Biostatistics and Statistical Bioinformatics Centre, KU Leuven, Leuven, Belgium.
Nursing and Healthcare Research Unit, Institute of Health Carlos III, Madrid, Spain.
Florence Nightingale School of Nursing and Midwifery, King's College, London.
Institute of Nursing Science, Basel, Switzerland.
School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland.
Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Center, IQ Healthcare, HB Nijmegen, Netherlands.



Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures.


For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics.


An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that 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.


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.


European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.

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