Hospital nurse staffing and patient outcomes in Chile – Author's reply
Authors: Linda H Aiken
Journal: The Lancet Global Health (2021)

We thank Motoi Miura and Tetsuya Tanimoto for their interest in our study. The intent of our Article on hospital nurse staffing and patient outcomes was to provide evidence that could inform acute hospital nurse workforce policies in Chile.1Aiken LH Simonetti M Sloane DM et al.Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study.Lancet Glob Health. 2021; 9: e1145-e1153Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar Our study had a rigorous design that included most large complex acute public hospitals, outcomes of 762 000 of their patients, and reports from 1652 direct care nurses practising in these same hospitals. Our large sample of hospitals, patients, and nurses is representative of complex, acute general hospitals in Chile. Our results suggest that policies to improve professional nurse staffing in these Chilean hospitals would probably save lives and result in improved patient satisfaction, and that savings from shorter hospital stays associated with improved nurse staffing could offset the costs of employing more nurses. We studied features of acute hospitals that are potentially modifiable in the short term by policy and managerial intervention. Patient-to-nurse staffing ratios are directly modifiable by the government; the demographics of nurses much less so. Our findings illustrate that even given the relatively young age and experience composition of the Chilean hospital nurse workforce, better nurse staffing is a promising strategy for substantially improving patient outcomes such as mortality and patient satisfaction and for gaining greater economic efficiency through avoidance of readmissions and through shorter hospital stays. Single studies rarely have findings that are generalisable to all countries and types of settings, and we make no such claim. However, our Chile study is part of a large body of international research, including RN4CAST, that used a similar research protocol in over 20 countries with differently organised and financed health-care systems and with differing average nurse age and experience levels, including the US,2Lasater KB Aiken LH Sloane DM et al.Is hospital nurse staffing legislation in the public's interest? An observational study in New York State.Medical Care. 2021; 59: 444-450Crossref PubMed Scopus (14) Google Scholar South Korea,3Cho E Sloane DM Kim W et al.Effects of nurse staffing, work environments, and education on patient mortality: An observational study.Int J Nurs Stud. 2015; 52: 535-542Crossref PubMed Scopus (162) Google Scholar European countries,4Aiken LH Sloane DM Bruyneel L et al.Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.Lancet. 2014; 383: 1824-1830Summary Full Text Full Text PDF PubMed Scopus (1136) Google Scholar and Australia.5McHugh MD Aiken LH Sloane DM et al.Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.Lancet. 2021; 397: 1905-1913Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar The results of the RN4CAST studies are remarkably similar across countries, showing consistently that lower hospital patient-to-nurse ratios are associated with lower mortality. Taken together, this large body of research suggests the generalisability of results to acute general hospitals in developed countries. We see no evidence that the association between nurse staffing and mortality is affected by the age and experience composition of nurses; there is an independent effect of the proportion of nurses with bachelor's qualifications on mortality.4Aiken LH Sloane DM Bruyneel L et al.Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.Lancet. 2014; 383: 1824-1830Summary Full Text Full Text PDF PubMed Scopus (1136) Google Scholar We agree that mortality is not an appropriate outcome measure in long-term care research. We find that better nurse resources are equally important to patient wellbeing in all health-care settings, including long-term care and ambulatory care by using non-mortality outcome measures. I declare no competing interests. Hospital nurse staffing and patient outcomes in ChileLinda Aiken and colleagues (August, 2021)1 studied the relation between nurse staffing and work environment and several clinical indicators, and they concluded that improved hospital nurse staffing in Chile was associated with better outcomes, such as lower 30-day hospitalisation mortality. Although this study is very important for providing quality nursing care, the generalisability of the results might be limited by several points. Full-Text PDF Open AccessHospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional studyImproved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value. Full-Text PDF Open Access