Effects of nurse staffing, work environments, and education on patient mortality: An observational study
Introduction
South Korea has undergone changes in health care services since the National Health Insurance system was introduced in 1989. Although South Korea has achieved a remarkable expansion of acute hospital services, the quality of health care has been rated lower than the average of the Organization for Economic Cooperation and Development (OECD) member countries (OECD, 2012). For example, South Korea has the highest mortality rates for acute myocardial infarction among OECD countries (OECD, 2012). Furthermore, South Korea has not been able to submit patient safety data to the OECD due to a lack of monitoring systems and patient safety policies (Park, 2012).
According to recent comparisons of nurse-rated quality of care in nine countries—the United States, China, South Korea, Thailand, Japan, New Zealand, the United Kingdom, Canada, and Germany—South Korean nurses were more likely than nurses in other countries to report that the quality of care on their unit was only fair or poor (Aiken et al., 2011b). The quality of care was judged to be fair or poor by 68% of nurses in South Korea compared to only 11% in Canada. This finding suggests that South Korean health care systems need to develop appropriate strategies for improving health care quality and safety.
Adequate nursing care is essential for health care quality and safety. Nurses are in a good position to detect patient problems (Clarke and Aiken, 2003), which is one reason that nurse staffing, nurse work environments, and nurse education appear to have significant effects on patient outcomes. Nurse surveillance, which involves the ongoing observation, assessment, recognition and interpretation of patient data, is a critical component of nursing care (Kutney-Lee et al., 2009). As around-the-clock care providers, nurses act as the hospital's surveillance system for the early detection and prevention of adverse events (Clarke and Aiken, 2003). Surveillance is directly influenced by the organizational structure of the hospital (Clarke and Aiken, 2003, Kutney-Lee et al., 2009). Adequate nurse staffing allows nurses to spend the most time with patients, while better nurse education and a favorable nurse practice environment influence the timeliness of interventions once a potential or acute patient problem has been identified. Among patient outcomes, mortality is the most important and often used indicator of quality of care at hospitals. A number of large-scale studies conducted in the North America (Aiken et al., 2011a, Estabrooks et al., 2005, Kane et al., 2007, Needleman et al., 2011, Shekelle, 2013) and recently in Europe (Aiken et al., 2014) have documented an association between nursing factors and hospital mortality.
An inadequate nurse work environment – a work environment lacking in adequate resources, strong nurse leadership, collegial relationships between nurses and physicians, ardent nurse participation in hospital affairs, and a solid nursing foundation for quality of care – also appears to negatively affect both nurses and patients. Poor work environments that make it difficult for nurses to perform their professional roles have been shown in studies of hospitals in the U.S., Europe and China to lead to nurse burnout and dissatisfaction, to poorer quality of patient care, and to lower patient satisfaction and worse patient outcomes, including mortality (Aiken et al., 2011a, Aiken et al., 2011b, Aiken et al., 2012, Estabrooks et al., 2005, Kazanjian et al., 2005). A recent study revealed that only 28.8% of Korean hospitals were categorized as having a better work environment than average, while 33.3% to 45.5% of hospitals in other countries were rated as having an above-average work environment (Aiken et al., 2011b). Furthermore, the Korean hospitals were rated as having the highest rates of nurse burnout (Aiken et al., 2011b).
The level of nurse education also appears to affect patient outcomes. Many recent studies have reported that, when the proportion of nurses with a Bachelor's or higher degree is high, patient mortality is low (Aiken et al., 2011a, Aiken et al., 2014, Blegen et al., 2013, Kutney-Lee et al., 2013, Van den Heede et al., 2009). There are two educational systems for nurses in South Korea. One is an associate's degree program in which a three-year nursing education curriculum is provided at a community college level. The other is a Bachelor's degree program offered at a four-year university level. When looking at the proportions of the 12,578 new students enrolled in nursing majors in 2009 in South Korea, students in three-year programs accounted for 60.5% of all students, while four-year nursing students accounted for only 39.5% (Lee, 2012). In addition, only 43.7% of nurses working in Korean hospitals with more than 100 beds have a Bachelor's degree or higher (Aiken et al., 2011b).
There is evidence in other countries that nurse staffing, work environments, and education are associated with patient mortality. However, there have been only two studies in South Korea suggesting that nurse staffing is associated with patient mortality, and both focused on intensive care units (Cho et al., 2008, Cho and Yun, 2009). Moreover, the impacts of variation in nurse education and work environments have not been studied in South Korea in relation to patient mortality. Thus, the purpose of this study was to investigate the effects of nurse staffing, work environment, and education on patient mortality in general acute care hospitals in South Korea.
Section snippets
Design
This study uses data from multiple sources in an attempt to replicate and extend, using data from South Korea, the findings of Aiken and colleagues showing the relationships of hospital nursing characteristics with patient mortality in the United States and Europe (Aiken et al., 2011a, Aiken et al., 2014). We combined (1) data on nurse staffing, work environments, and education from surveys of nurses with (2) data on patient characteristics and other information (including 30-day mortality)
Characteristics of hospitals, nurses, and patients
The characteristics of the 14 study hospitals and the numbers and percentages of nurses surveyed in and patients discharged from hospitals with various characteristics are shown in Table 1. Ten of the 14 hospitals (71.4%) were located in metropolitan areas, and those hospitals accounted for 853 (83.3%) of the surveyed nurses and 62,867 (82.7%) of the discharged patients. Seven hospitals (50%) had 1000 or more beds, and those hospitals employed 637 (62.2%) of the nurses and discharged 51,185
Discussion
In this study, each nurse was, on average, caring for 11.4 patients, with significant variation in workload across hospitals. Thus, nurses in South Korea care for about twice as many patients as do nurses in the United States (5.7 patients) (Aiken et al., 2013a) and some European countries, including Finland (5.5 patients), Sweden (5.4 patients), and Norway (3.7 patients) (Aiken et al., 2013b). Our findings confirm that higher ratios of patients to nurses is associated with higher patient
Conclusions
The study results suggest that higher patient to nurse workloads, poor work environments, and fewer BSN nurses in South Korean hospitals may be responsible for preventable hospital deaths. Nurse staffing at major Korean teaching hospitals does not compare favorably with staffing in other developed countries, the work environments at some of these important hospitals were poor, and some hospitals had small percentages of BSN nurses. Improving nurse staffing and nurse work environments and
Acknowledgements
The authors thank to the nurse executives and staff nurses of hospitals, and the executives of the Korea Hospital Nurses Association who contributed to this research. Special thanks to Tim Cheney for his contributions to the analysis.
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