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More university-educated RNs and staff satisfaction could help reduce hospital death rates


A new study from the Institute for Clinical Evaluative Sciences (ICES) shows that Ontario hospitals which employ a higher proportion of university-trained registered nurses (RNs), who feel their employer institution has adequate staffing, resources, and quality of care, have lower 30-day patient mortality rates.

“Over the past two decades, increasing attention has been focused on the impact of nursing care on hospitalized patient mortality and survival,” said Dr. Ann Tourangeau, ICES adjunct scientist, professor at the University of Toronto, and lead author of the study.

“However, the relatively small number of studies available has yielded inconsistent and incomplete knowledge of the impact of hospital structures and processes on patient mortality.”

In order to provide a clearer perspective on this issue, investigators surveyed nurses working in medical and combined medical-surgical units in 75 Ontario teaching and community hospitals between February and May 2003. They linked these nurse survey data with data on 46,993 patients admitted to hospital with heart attacks, stroke, pneumonia, and blood poisoning between April 1, 2002 and March 31, 2003 in order to determine nursing-related elements that may impact 30-day mortality.

On average, the 30-day hospital mortality rate was 17%. The results also showed that:

  • A 10% increase in the proportion of RNs in the staffing mix was associated with six fewer deaths per 1,000 discharged patients.
  • A 10% increase in the number of university-educated nurses was associated with nine fewer deaths per 1,000 discharged patients.
  • A 10% increase in nurse-reported adequate staffing and resources was associated with 17 fewer deaths per 1,000 discharged patients.
  • A 10% increase in nurse-reported use of care maps or protocols to guide patient care in a hospital was associated with 10 fewer deaths for every 1,000 discharged patients.

Dr. Tourangeau and her fellow investigators recommended that, “if hospitals have goals of minimizing unnecessary patient death for their acute medical patients, they should maximize the proportion of RNs providing direct care, aggressively seek to hire and retain university-educated nurses, and make a significant investment in the development, use and systematic updating of care maps or protocols to guide patient progress throughout hospitalization.”

The study, “Impact of hospital nursing care on 30-day mortality for acute medical patients”, is in the latest issue of the Journal of Advanced Nursing.

Author affiliations: ICES (Drs. Tourangeau and Tu); Faculty of Nursing, University of Toronto (Drs. Tourangeau, Doran, McGillis Hall, O’Brien Pallas, Pringle, and Ms. Cranley).

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.


  • Julie Dowdie
  • Media Relations Officer, ICES
  • (416) 480-4780 or cell (416) 432-8143


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