News Release

Better nurse staffing and education reduces patient deaths in European hospitals

Peer-Reviewed Publication

University of Pennsylvania School of Nursing

Dr. Linda H. Aiken, University of Pennsylvania School of Nursing

image: This is a photo of Dr. Linda H. Aiken, Professor of Nursing and Sociology and Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. view more 

Credit: University of Pennsylvania School of Nursing

The Lancet reported today the results of a study in 9 European countries documenting that hospital nurse staffing and the proportion of nurses with bachelor’s education are associated with significantly fewer deaths after common surgery. A team of researchers led by the University of Pennsylvania School of Nursing in the U.S. and Catholic University of Leuven in Belgium, found that every one patient increase in patient to nurse ratios was associated with a 7% increase in deaths, while having a better educated nurse workforce is associated with fewer deaths. Every 10% increase in bachelor’s degree nurses is associated with a 7% decline in mortality.

This study of close to a half million surgical patients in 300 hospitals found that patients in hospitals in which 60 percent of nurses had bachelor’s degrees and cared for an average of six patients had nearly a one-third lower risk of death after common inpatient surgical procedures than patients in hospitals where half as many nurses had bachelor’s degrees and cared for an average of eight patients each. The RN4CAST study, funded by the European Union and the National Institute of Nursing Research, National Institutes of Health, concluded that in Europe, as in the U.S., failing to invest in bachelor’s nurse education and attempts to cut costs by reducing nurse staffing may put hospitalized patients at greater risk of dying.

“Our results suggest that the assumption that hospital nurse staffing can be reduced to save money without adversely affecting patient outcomes may be foolish at best, and fatal at worst,” said Linda H. Aiken, Professor of Nursing and Sociology, and Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. “Hospitals should take notice because when budgets are tight, cutting back on nurses is often the first step but one that can have disastrous consequences for patients.”

The study’s results closely dovetail with research conducted in the U.S. that served as a catalyst for public and private responses to improve nurse staffing and nurses’ education. Nearly half the states in the U.S. “have implemented or are considering hospital nursing staffing legislation and/or regulation,” the study’s authors report. Additionally the Institute of Medicine of the U.S. National Academy of Sciences has recommended a U.S. national nurse workforce that is 80 percent bachelor’s educated by 2020.

Similar initiatives are much less common in Europe. The recent Francis and Keogh reports in England investigating poor outcomes for hospital patients concluded that inadequate nurse staffing contributed to preventable deaths, reported the authors.

In Europe, the proportion of hospital nurses with bachelor’s degrees varies significantly across countries. Some hospitals studied had no nurses with bachelor’s qualifications while all nurses in Norway and Spain are required to be bachelor’s qualified. The European Parliament, in its continuing efforts to foster occupational mobility across EU member countries, side-stepped the issue of nurse qualifications in October 2013 by approving two very different educational pathways for nurses. One newly recognized pathway leads to bachelor’s education but the other maintains a vocational training track to prepare nurses after only 10 years of secondary school. The findings of the Lancet paper suggest that continued EU recognition of vocational training for nurses may adversely affect patient outcomes and nurses’ access to university education in some countries.


For additional information, contact the lead author, Dr. Linda Aiken at the University of Pennsylvania Phone: 215-898-9759, or refer to for details on the countries studied and contact information for research teams in each country.

The paper will be posted after the embargo date at:

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.