Perspectives: European Academy of Nursing Science Debate

Abstract

The 2014 EANS Cohort

‘This house believes that increasing the nurse–patient ratio is both a necessary and sufficient method of improving access to high quality.’

Introduction

The European Academy of Nursing Science (EANS) is an independently organised body comprising individuals who have made significant contributions to the advancement of nursing science in Europe through scholarship and research (European Academy of Nursing Science, 2015). Established in 1998, EANS aims to be the leading nursing academy providing inspiration, collaboration and academic leadership in Europe. The academy provides a forum for established and early nurse researchers to develop a European perspective and collaborations to their work.

One of its central activities is an annual doctoral summer school, where nurse doctoral candidates from across Europe gain exposure to a common European perspective on nursing research. Participants attend three consecutive summer schools held across Europe. A two day EANS conference is held during the summer school, attended by members of EANS, and second year students are expected to prepare and present a formal debate as part of the conference proceedings. Students work in six randomly allocated multistate groups where three groups prepare material in support of a motion, three against it. The 2015 EANS summer school and conference were held in Barcelona, Spain.

Debate is a unique opportunity to prepare an argument for or against a motion based on evidence – whether or not they subscribe to the position they are asked to support. Preparation within teams where for most English is not the first language and coming from a wide range of nursing and geographical backgrounds presents opportunities and challenges in equal measure. Debate allows important issues to be explored thoroughly in a manner that is blatantly competitive but that gives an equal amount of time to both sides of the argument (McKenna et al., 2010).

Debate takes the style of the British parliament, where the audience is referred to as the house. This in itself can be confusing to participants not from the UK, but speeches are made in turn by making a case for the motion and then opposing it. A chair accustomed to the rules of debate and public speaking is appointed to manage proceedings. The house votes at the beginning of the debate and then again at the end, basing the second vote on the persuasiveness and skills of the proposers and opposers to the motion.

The 2015 debate players

The chair, Professor Peter Griffiths (University of Southampton) took a vote at the beginning of the debate and again at the end. The initial vote demonstrated a significant majority against the motion. The second vote showed a swing of votes towards the proposers, but the motion was defeated.

Proposing the motion

Holmberg Fagerlund, B; Holmgren, M; Mitrea, N; Adam, C; McCallum, L.

‘Quality care is safe, effective, patient-centred, timely, efficient, and equitable’ (Institute of Medicine, 2001). The nurse plays a central role in delivering and determining the overall quality of patient care. The Francis Report (The Mid-Staffordshire NHS Foundation Trust, 2013), a national inquiry into substandard and inadequate care in England, highlighted the severe consequences and impact that reduced nurse–staff ratios have on the quality and safety of patient care. This serves as a stark reminder of the negative impact on patients and their families when finance and cost are given supremacy over care, compassion and patient need. Thankfully, similar reports of such atrocities arising in other European countries are rare, but across Europe access to a nurse is not equitable. The study of Aiken et al. (2014) demonstrated that nurse-staffing ratios vary greatly from country to country. In England the average ratio was 1:8.6, while in Greece it is as high as 1:10.2, whereas legislation in Romania (Legea 1224/2010) denotes the standard for nurse–patient staffing ratio is 1:22.

In recognition of the vital contribution that nurses make to the quality of patient care, a key recommendation arising from the Francis Report (The Mid-Staffordshire NHS Foundation Trust, 2013), the Keogh Report (Keogh, 2013) and Berwick Report (NHS, 2013) is that nurse staffing levels and skill mix should appropriately reflect patient caseload and severity of patient illness. One size does not fit all, but inadequate nurse staffing levels equate to poor quality of care.

The pan European research study of Aiken et al. (2014) found that an increase in a nurses’ workload by only one patient increases the likelihood of inpatient death within 30 days of admission. Moreover, qualified hands make a difference. For every 10% increase in the number of nurses with a bachelor degree, there was an associated decrease of 7% in the likelihood of inpatient death. Primarily, we need more qualified nurses to ensure that nurses are furnished with appropriate resources to deliver care that they have been educated to provide to the vulnerable members of our society.

A study by Ball and colleagues (2013), in which nurses from acute medical and surgical wards were asked to report on how workload affected the care that they provided, found that 86% of nurses reported that at least one out of 13 care activities was missed or left undone due to poor staffing levels and high workload on their last shift. On average four activities were omitted. This included comforting/talking with patients (66%), educating patients (52%), developing/updating care plans (47%) and in 7% of reports, pain management could not be addressed. Clearly, when nurse staffing levels are poor the fundamental aspects of care suffer. Chronically poor nurse staffing levels can lead to moral distress and nurse burnout, which themselves are associated with poor organisational culture and quality of care (Boorman, 2009).

While increased staffing ratios might not be the only determinate of quality of care: ‘… poor staffing levels make good quality nursing care near on impossible’ (Ball, 2014: 489).

Opposing the motion

Geense, W; Heczkova, J; Bergman, M; Beck, E-R; Soberg Finbraten, H.

When first presented with the motion, the initial reaction may be one of consensual agreement. However, on closer inspection it should be noted that there are multiple conditions that need to be addressed:

How to define access to high quality care and improvement?

And, should we succeed in defining these two objectives, is increasing the nurse patient ratio the only necessary and sufficient intervention?

Being nurses, we can all see the benefits of an increased number of nurses working at patient level, but are we really saying this equates to increased access to quality of care?

Nurses might increase patients’ access to quality care (Shepherd, 2015). However, this is also determined by the knowledge and competency of the nurses. This is why it is so difficult to imagine that just increasing staffing can be sufficient. What about the quality of the nurses? Quantity cannot replace quality.

Over the past decade there has been a surge in literature focusing on staffing ratios and the subsequent effect on patient care. Although several studies indicate that a higher nurse–patient ratio is associated with less hospital mortality and complications, such results seem to be inconsistent.

In an extensive systematic review (Kane et al., 2007) involving 94 empirical studies looking at the relationship between nurse–patient ratios and patient-related outcomes, it was concluded that outcomes such as hospital-related mortality were reduced. However, there was no causal relationship between increasing nursing numbers and subsequent improvements in patient outcomes. The authors emphasise the possibility that hospitals investing in more nurses may also invest in other actions improving quality. Furthermore, hospitals with a greater percentage of nurses with bachelor degrees, higher job satisfaction and autonomy were associated with a significant reduction in the risk of death.

Nurse staffing ratios is a complex issue. Douglas (2010) identified 36 nurse staffing factors, of which the nurse–patient ratio was only one. Kane et al. (2007) also emphasised other issues such as staffing characteristics, patient factors such as age, diagnosis or comorbidity and organisational factors such as access to technology as having an influence on patient outcomes.

So the process of access to high quality health care is far more complex than merely increasing the numbers of nurses. It is dependent on collaboration between all members of the multidisciplinary team. Of course increasing the ratio of nurses to patients is a good thing, but we doubt that it is sufficient to increase access to good quality care. Nurse staffing is only one piece of a much larger jigsaw puzzle. One piece alone cannot make a complete picture, it needs to be linked and supported by the other pieces.

Second for the motion

Bringsvor, HB; do Carmo Lemos Vieira Gouveia, M; Lauritzen, J; Sahlström, M; Vandecasteele, T.

There is safety in numbers. Findings from the RN4CAST study highlight how an increase in the workload of nurses increases the likelihood of inpatient deaths across Europe (Aiken et al., 2014). This particular study pointed out how every one patient increase in the patient–nurse ratio is associated with a 7% increase in deaths, signifying a striking impact of the patient–nurse ratio on mortality. We can also reflect on other patient outcomes and consider how nurse–patient ratios affect quality of care and the risk of complications. The same RN4CAST study showed that ratings of patient experience, safety and quality of care in hospitals was lower when there were fewer nurses. Likewise, results from a cross-sectional survey of 2917 nurses in England concluded that nurses were more likely to omit necessary care when they were working shifts with higher numbers of patients per nurse (Ball et al., 2013). Substantial research shows a positive relationship between nurse staffing levels and patient outcomes. This means that when admitted to a hospital with an increased amount of patients assigned to a nurse, there is a higher risk of complications such as pneumonia (Dimick et al., 2001; Hope, 2003; Mark et al., 2004), shock or cardiac arrest (Dang et al., 2002; Pronovost et al., 2001), failure to resuscitate (Aiken et al., 2002; Halm et al., 2005), respiratory failures (Dang et al., 2002; Dimick et al., 2001), urinary tract infections (Needleman et al., 2002) or other bloodstream infections (Dang et al., 2002; Hope, 2003; Needleman et al., 2002). All of these entail longer hospital stays (Khan et al., 2006; Yadla et al., 2015). Consequently, preventing these complications will be of significant importance for individual patients and for the health care community, and through reduction in length of hospital stay, money can be saved in the long run (McCloskey and Diers, 2005; McCue et al., 2003; Papas, 2008). Moreover, in considering the cost-effectiveness of various nurse staffing ratios, Rothberg et al. (2005) conclude that as a patient safety intervention, improving nurse staffing has a cost-effectiveness that falls comfortably within the range of other commonly accepted interventions.

There are also implications for nurses. Nurses who are responsible for high ratios of patients report higher work-related stress and anxiety (Carayon and Alvarado, 2007), higher rates of burnout (Van Bogaert et al., 2013), feelings of vulnerability (Abu Al Rub, 2004) and risk of making mistakes (Aiken et al., 2001; Letvak and Buck, 2008; Van Bogaert et al., 2013), thus compromising the health of the entire community (Armstrong, 2009). In addition, nurses themselves describe clinically competent nurses and adequate staffing as two of the essential elements needed to improve quality of nursing care (Kieft et al., 2014). Indeed quality of care is shown to improve when staffing is adequate (Gordon et al., 2008; Tourangeau et al., 2006).

In considering the implications for both patients and nurses, we can conclude that increasing the number of nurses is necessary to increase health care quality.

Second opposition to the motion

Bökberg, C; Castaldo, A; Selnes Haugdahl, H; Huber, C; Sipilä, M; Smith-Strom, H.

It is necessary to increase the nurse–patient ratio but this factor alone is not sufficient to access high quality health care. There are many ways to improve quality and patient safety in hospitals, community and primary care. Needleman et al. (2006) have described a number of additional factors to influence access to high quality health care besides increasing nurse staffing alone. These include equipping hospitals with new technology, investing in training and education of nurses, and imposing regulations.

Mobile technology and related e-health innovations in particular have the potential to ease access to reliable health care information. The EANS key note address by Shepherd (2015) suggested that it is increasingly common for knowledge and data to be exchanged over longer distances and sometimes even between continents. Also access to blood tests for genetic screening can make a huge difference to peoples’ lives, although this needs careful considerations of patients’ expectations and emotional support (Chao et al., 2008, Esplen et al., 2013). Therefore, it is not sufficient solely to increase the nurse–patient ratio. We also need training and education for nurses and other health care professionals.

It is essential that nurses have the training and education to achieve the competences necessary to deliver safe and high quality services as mandated in the European Directive 2013/55/EU (amending Directive 2005/36/EC) on the recognition of professional qualifications (European Union, 2013). In addition, European Directive 2011/24/EU on the application of patients’ rights in cross-border health care (European Union, 2011) supports investing in health services and building health care networks for the benefit of people living in Europe (Palm et al., 2013). A feasible way forward to achieve better involvement in health care decision is to empower people, including nurses, to participate in shared decision making. This needs education for both nurses and patients. Enhanced competences of nurses, who deliver such health care services, will succeed in better health care outcomes.

In a study by van Oostveen et al. (2015), nurse staffing is seen as the tip of the iceberg. Below the surface are other influencing factors such as nursing behaviour, authority and autonomy. These components are linked by an overarching theme, that of nurse position. Nurse position is context specific, and still today nurses legally have a subservient position in many countries (McMurray, 2011, Ng’ang’a and Byrne, 2015). This position cannot be changed by simply increasing the nurse–patient ratio. These factors are best influenced politically and involve an organisational culture of fairness and justice (Kuokkanen et al., 2014). Nursing care needs to be more visible. Nurses must invest in training and education and become more politically involved to raise their own voices in health care decisions.

As we know from the systematic review of Backhaus et al. (2014), there is no consistent relationship between nurse staffing and quality of care in nursing homes. It is necessary to improve the nurse–patient ratio but this alone is not sufficient to improve access to high quality health care.

Right to reply for the motion

Masià-Plana, A; Terkamo-Moisio, A; Hope Kolltveit, B-C; Gesar, B; Richter, C.

We have heard many interesting arguments regarding access to health care, but we are all aware of new research such as the RN4CAST (Aiken et al., 2014), which explores the relationship between nurse-staffing and broader aspects of hospital organisation and patient outcomes. It reveals the severe impact of nurse staffing on patient outcomes. It has also been said that access to quality health care should be developed at the multidisciplinary level, but we believe that nurses are one of the most important and relevant professionals within the whole health care system.

At the EANS conference Richards (2015) discussed access to health care, describing it as the equitable, acceptable and effective utilisation of person-centred health care from an adequate supply, which is sensitive and appropriate to different perspectives, both individual and cultural.

As such, increasing the number of qualified nurses is a sufficient method to improve access to high quality health care. Nurses have specific skills that few other professionals have and based on nurses’ specific education, these professionals are not just able to provide care to people already ill, but those who are healthy too. Early detection of changes in a person’s health, which could lead to severe incidents, enables nurses to prevent many illnesses and preserve people from unnecessary harm or illness.

The World Health Organization (2014) points out the impact of socioeconomic status on a population’s health. In addition to the prevention of illness, health promotion is an essential part of nurses’ work.

Increasing the number of nurses not only improves their capacity to undertake significant work, it would also have a positive impact on the economy at a societal level. Healthy people need fewer health care services, which means shorter waiting lists and improved access to health care for everybody.

Research in nursing science gives us tools to deliver the best possible care to people at all stages of their lives. For this reason, a greater amount of qualified nurses would be beneficial to society and improve individual health, whose needs would be covered more sufficiently in an evidence-based professional manner, based on a strong ethical commitment.

Other professionals could do nurses’ work as well to some extent, but we should at least consider the possibility that an increased number of qualified nurses is a cost-effective investment for patient safety (Griffiths, 2014). There is no other professional educated to observe, analyse, preserve, prevent and promote the health of human beings.

Right to reply against the motion

McCloskey, S; Drury, A; Brubakk, K; Glarcher, M; LeBlanc, J; Ambrosio Gutierrez, L.

There have been many valid points made of which we should take note. However, the motion fails on the basis of sufficiency. We propose that improved access to high quality health care is not related to increasing the nurse–patient ratio alone. We cannot identify a causal relationship between nurse–patient ratios and access to quality health care. The reality is more complex and needs to be considered across multiple levels. Gulliford et al. (2002) point out that access is reliant on the availability of adequate services, yet this is only one dimension as gaining access is often inhibited by financial, organisational, cultural and social barriers that impact on diverse communities in different ways. Globally, we are reminded that access to health care is better for some on the basis of (among other things) gender (Asfaw et al., 2010), cultural and ethnicity (Ellison-Loughman and Pierce, 2006), disability (Tuffrey-Wjine et al., 2014), financial wealth (Andersen and Davidson, 2007), sexual orientation (Kates et al., 2015) and geography (Scheil-Adlung, 2015).

Furthermore, in many European countries there is a societal expectation that universal health services will be provided in a manner that responds to individuals’ needs. Yet due to multiple pressures including longer life expectancy and the costs of care associated with managing chronic conditions, along with the capacity to treat more through expensive medications, many of us live in a world of health care rationing. In a comparative study across four European countries, Redwood (2000) highlighted that rationing ‘the allocation and prioritization of health care resources’ (p. viii) results in a range of symptoms including long waiting lists, denial of quality treatment and discrimination of patients regardless of need (p. viii). Such political decisions impact on the supply and equitability of access to services at a national level.

Utilisation of services is also influenced by organisational factors. In a Canadian study, Degenhardt (2011) highlighted a global reality in which higher mortality rates are linked to patients admitted to hospital at weekends compared to during the week. She concluded that while nurse–patient ratios have a part to play, wider organisational factors such as access to on-site intensivists, access to diagnostics and movement to a ‘true’ seven day a week service needs to be considered if this disparity is to be addressed. The organisational level of quality in health care provision is linked to such factors as leadership, planning, utilisation of resources, staff education and training and collaborative engagement between those working in the health care system and those who use the services (Mosadeghrad, 2014).

So what does this mean for the nursing profession? Do we hold on to a belief that increasing nurse–patient ratios is essential for increasing not only access to, but also the experience of, quality health care and argue for this alone? We agree with the view of Griffiths (2009) that currently the evidence is lacking to support this argument. Nurses can influence access to quality care through many means. It is not the number of nurses that is a critical factor, it is what nurses do.

Footnotes

Julie Taylor is a nurse scientist specialising in child maltreatment. She is Professor of Child Protection in the School of Nursing, University of Birmingham, in partnership with Birmingham Children's Hospital.

Pia Riis Olsen is lecturer, clinical nurse specialist and research nurse in the Department of Oncology, Aarhus University Hospital, Denmark.

References

Abu Al Rub

(2004) Job stress, job performance, and social support among hospital nurses. J Nurs Scholarship 36(1): 73–78.

Aiken

Clarke

Sloane

(2001) Nurses’ reports on hospital care in five countries. Health Affairs 20(3): 43–53.

Aiken

Clarke

Sloane

(2002) Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 288: 1987–1993.

Aiken

Sloane

Bruyneel

(2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 383: 1824–1830.

Andersen

Davidson

(2007) Improving access to care in America: Individual and contextual indicators. In: Andersen

Rice

Kominski

(eds) Changing the US healthcare system: Key issues in health policy and management, 3rd edn. San Francisco, CA: Jossey-Bass, pp. 3–31.

Armstrong F (2009) Ensuring quality, safety and positive patient outcomes. Why investing in nursing makes $ense. Australian Nursing Federation. ISBN: 978-0-909599-56-0.

Asfaw

Lamanna

Klasen

(2010) Gender gap for parents financing strategy for hospitalization of their children: Evidence from India. Health Econ 19: 265–279.

Backhaus

Verbeek

van Rossum

(2014) Nurse staffing impact on quality of care in nursing homes: A systematic review of longitudinal studies. J Am Med Dir Assoc 15: 383–393.

Ball J (2014) Nursing Safeguarding and Skill Mix Conference: Planning Nurse Staffing – why and how? Available at: http://www.healthcareconferencesuk.co.uk/news/jane-ball-deputy-director-national-nursing-research-unit-king-s-college-london-speaking-today-at-the-nursing-safeguarding-and-skillmix-conference-in-london-asked-planning-nurse-staffing-why-and-how (accessed 13 February 2016).

10.

Ball

Murrells

Rafferty

(2013) ‘Care left undone’ during nursing shifts: Associations with workload and perceived quality of care. BMC Quality Safety 23: 116–125. doi: 10.1136/bmjqs-2012-001767. Available at: http://qualitysafety.bmj.com/content/early/2013/07/08/bmjqs-2012-001767.full.pdf+html (accessed 7 August 2015).

11.

Boorman S (2009) NHS Health & Wellbeing. Final Report. Department of Health. Available at: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108907.pdf (accessed 7 August 2015).

12.

Carayon

Alvarado

(2007) Workload and patient safety among critical care nurses. Crit Care Nursing Clin North Am 19: 121–129.

13.

Chao

Roberts

Marteau

(2008) Health behavior changes after genetic risk assessment for Alzheimer disease: The REVEAL Study. Alzheimer Dis Assoc Disord 22(1): 94–97.

14.

Dang

Johantgen

Pronovost

(2002) Postoperative complications: Does intensive care unit staff nursing make a difference? Heart & Lung 31(1): 219–228.

15.

Degenhardt

(2011) Increased mortality among the critically ill patients admitted on weekends: A global trend. Dynamics 22(3): 14–18.

16.

Dimick

Swoboda

Pronovost

(2001) Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy. Am J Crit Care 10: 376–382.

17.

Douglas

(2010) Ratios: If it were only that easy. Nurs Econ 28: 119–125.

18.

Ellison-Loschmann

Pearce

(2006) Improving access to health care among New Zealand’s Maori population. Am J Public Health 96: 612–617.

19.

Esplen

Cappelli

Wong

(2013) Development and validation of a brief screening instrument for psychosocial risk associated with genetic testing: A pan-Canadian cohort study. BMJ Open 3(3): e002227.

20.

European Academy of Nursing Science (2015) Available at: http://www.european-academy-of-nursing-science.com/ (accessed 13 February 2016).

21.

European Union (2011) Directive 2011/24/EU: The Application of Patients’ Rights in Cross-border Healthcare. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/252940/Cross_Border_Healthcare_Information.pdf (accessed 17 February 2016).

22.

European Union (2013) Directive 2013/55/EU: The Recognition of Professional Qualification. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2013:354:0132:0170:en:PDF (accessed 13 February 2016).

23.

Gordon

Buchanan

Bretherthon

(2008) Safety in numbers: Nurse-to-patient ratios and the future of health care, New York: Cornell University Press, pp. 150.

24.

Griffiths

(2009) RN + RN = better care? What do we know about the association between the number of nurses and patient outcomes? Intl J Nurs Stud 46: 1289–1290.

25.

Griffiths

(2014) Nurse patient ratios, skill mix and work futures. Int J Nurs Stud 51: 353–354.

26.

Gulliford

Figueroa-Munoz

Morgan

(2002) What does ‘access to health care’ mean? J Health Serv Res Policy 7: 186–188.

27.

Halm

Peterson

Kandels

(2005) Hospital nurse staffing and patient mortality, emotional exhaustion, and job dissatisfaction. Clin Nurse Specialist 19: 241–251.

28.

Hope J (2003) Nosocomial Infections and Their Relationship to Nursing Workload in an Acute Care Hospital [dissertation AAT MQ86117]. Ottawa, Ontario, Canada: Queen’s University, 2003.

29.

Institute of Medicine (2001) Crossing the quality chasm: a new health system for the 21st century, Washington, DC: National Academy Press.

30.

Kane RL, Shamliyan T, Mueller C, et al. (2007) Nurse staffing and quality of patient care. Available at: http://archive.ahrq.gov/downloads/pub/evidence/pdf/nursestaff/nursestaff.pdf (accessed 13 February 2016).

31.

Kates

Ranji

Beamesderfer

(2015) Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender Individuals in the US. (July; Issue brief), California: The Henry J Kaiser Family Foundation.

32.

Keogh B (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England: Overview report. NHS England. Available at: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf (accessed 13 February 2016).

33.

Khan

Quan

Bugar

(2006) Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med 21: 177–180.

34.

Kieft

de Brouwer

Francke

(2014) How nurses and their work environment affect patient experiences of the quality of care: A qualitative study. BMC Health Serv Res 14: 249. doi: 10.1186/1472-6963-14-249.

35.

Kuokkanen

Leino-Kilpi

Katajisto

(2014) Does organizational justice predict empowerment? Nurses assess their work environment J Nurs Scholarship 46: 349–356.

36.

Letvak

Buck

(2008) Factors influencing work productivity and intent to stay in nursing. Nurs Econ 26: 159–165.

37.

McCloskey

Diers

(2005) Effects of New Zealand’s health reengineering on nursing and patient outcomes. Med Care 43: 1140–1146.

38.

McCue

Mark

Harless

(2003) Nurse staffing, quality, and financial performance. J Healthcare Finance 29(4): 54–76.

39.

McKenna

Porock

Mead

(2010) RCN Research Society International Conference, Gateshead, May 2010. J Res Nurs 15: 471.

40.

McMurray

(2011) The struggle to professionalize: An ethnographic account of the occupational position of advanced nurse practitioners. Hum Relat 64: 801–822.

41.

Mark

Harless

McCue

(2004) A longitudinal examination of hospital registered nurse staffing and quality of care. Health Serv Res 39: 279–300. doi: 10.1111/j.1475-6773.2004.00228.x.

42.

Mosadeghrad

(2014) Factors influencing health care service quality. Intl J Health Policy Manage 3: 77–89.

43.

Needleman

Buerhaus

Mattke

(2002) Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 346: 1715–1722.

44.

Needleman

Buerhaus

Stewart

(2006) Nurse staffing in hospitals: Is there a business case for quality? Health Aff (Millwood) 25: 204–211.

45.

Ng’ang’a

Byrne

(2015) Professional practice models for nurses in low-income countries: An integrative review. BMC Nurs 14: 44.

46.

NHS (2013) National Advisory Group on the Safety of Patients in England. A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England, London: NHS.

47.

Palm W, Glinos IA, Rechel B, et al. (2013) Building European reference networks in health care. Exploring concepts and national practices in the European Union. (European Observatory on Health Systems and Policies). Available at: http://www.euro.who.int/en/about-us/partners/observatory/publications/studies/building-european-reference-networks-in-health-care.-exploring-concepts-and-national-practices-in-the-european-union (accessed 3 September 2015).

48.

Pappas

(2008) The cost of nurse-sensitive adverse events. J Nurs Admin 38: 230–236. doi: 10.1097/01.NNA.0000312770.19481.ce.

49.

Pronovost

Dang

Dorman

(2001) Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Effective Clin Pract 4: 199–206.

50.

Redwood

(2000) Why ration health care?, London: CIVITAS.

51.

Richards D (2015) Access to Health Care. In: Summer conference, European Academy of Nursing Science, Barcelona, 8–9 July.

52.

Rothberg

Abraham

Lindenauer

(2005) Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Med Care 43: 785–791.

53.

Scheil-Adlung X (ed.) (2015) Global evidence on inequities in rural health protection: New data on rural deficits in health coverage for 174 countries. Geneva: Labour Office, Social Protection Department.

54.

Shepherd M (2015) The generic diabetes nurse: Transforming diabetes care. In: Summer conference, European Academy of Nursing Science, Barcelona, 8–9 July.

55.

The Mid-Staffordshire NHS Foundation Trust (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary. London: Stationery Office (Chair: R Francis). Available at: www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf (accessed 24 August 2015).

56.

Tourangeau

Cranley

Jeffs

(2006) Impact of nursing on hospital patient mortality: A focused review and related policy implications. Qual Safety Healthcare 15: 4–8.

57.

Tuffrey-Wijne

Goulding

Giatras

(2014) The barriers to and enablers of providing reasonably adjusted health services to people with intellectual disabilities in acute hospitals: Evidence from a mixed-methods study. BMJ Open 4: e004606. doi: 10.1136/bmjopen-2013-004606.

58.

Van Bogaert

Clarke

Willems

(2013) Nurse practice environment, workload, burnout, job outcomes, and quality of care in psychiatric hospitals: A structural equation model approach. J Adv Nursing 69: 1515–1524. doi: 10.1111/jan.12010.

59.

van Oostveen

Mathijssen

Vermeulen

(2015) Nurse staffing issues are just the tip of the iceberg: A qualitative study about nurses’ perceptions of nurse staffing. Int J Nurs Stud 52: 1300–1309.

60.

World Health Organization (2014) Review of social determinants and the health divide in the WHO European Region. WHO Regional Office for Europe: Copenhagen. Available at: http://www.euro.who.int/__data/assets/pdf_file/0004/251878/Review-of-social-determinants-and-the-health-divide-in-the-WHO-European-Region-FINAL-REPORT.pdf (accessed 13 February 2016).

61.

Yadla

Ghobrial

Campbell

(2015) Identification of complications that have a significant effect on length of stay after spine surgery and predictive value of 90-day readmission rate. J Neurosurg Spine 23(6): 807–811.