In Hungary, the 60/2003. (X.20) ESzCsM order on minimum professional requirements necessary for providing health care services prescribes the ratio of direct nurses with different qualifications (category I-, II.- III.) full-time in a department with a given patient number. However, these numbers do not show the number of patients for one nurse in one shift, or the severity classification of these patients. However, internationally, the number of nurses gets defined primarily by nurse/patient ratio, which determines the number of patients to one nurse in one shift. For calculating the ratios, the productive time period by severity category needs to be provided, i.e. how much time is needed to treat a patient during 24 hours, excluding time spent for education and administration. A dynamic system that takes better account of patient care needs can be introduced in line with international experience with nursing staff calculations corresponding to the severity of the patients.
In Hungary, it needs to considered that the administrative load for nurses is disproportionately large, which is the same as time spent on patient education, as the most important elements preceding e.g. hospitalization are patient management- and education (e.g. patients with diabetes, cancer patients, etc.) The number of weekly/monthly/ annual nursing hours and the number of nurses working full-time can be calculated from the number of daily nursing hours. By providing an optimal nurse/patient ratio as well as increasing the number of Bachelor nurses working directly patient bedside, the mortality rate can be decreased by at least 30%. (Part II.2. of the study details this human resources-development.)
A number of extensive inspections were made regarding the nurse/patient ratio. Among these, the study published in 2002 by Aiken and her colleagues has presented first that 1 nurse can be safely be responsible for 5 patients, above that, each patient added to nurses’ workloads was associated with a 7% increase in mortality following common surgeries. In 2010, they have examined the aftereffect of the California regulation in the entire hospital system of California, New Jersey and Pennsylvania states, regarding 130 indicators, and they have continually found that following the fifth patient, the assigning of further patients to the nursing activity of the nurse increases the mortality risk of the patient by a 1.13 (California)-, 1.10 (New Jersey)- 1.06 (Pennsylvania)- probability. Additionally to these facts, if the nurse-patient ratio would have reached the regulated California average in the hospitals of New Jersey and Pennsylvania, the mortality rate following surgery in New Jersey would have been 13.9% lower, in Pennsylvania it would have been lower by 10.6%.3, 53
Based on international literature, a nurse:patient ratio of 1:1 is recommended in the USA in case of operating room, trauma patients in emergency departments and labour&delivery (2nd and 3rd stages); in England, in case of ventilated patients in intensive care; in Canada, in case of unconscious (waking) patients in post-anesthesia units, in neonatal intensive care, in delivery rooms (1st, 2nd and 3rd stages), in case of ICU patients in emergency departments. In Canada, a nurse:patient ratio of 2:1 is recommended in case of operating room, in Australia, a nurse:patient ratio of 2:3 is recommended in delivery rooms (1st, 2nd and 3rd stages). In the USA, a nurse:patient ratio of 1:2 is recommended in case of post-anesthesia patients(California), in case of intensive care patients, neonatology intensive care, in case of a patient treated in emergency departments requiring intensive therapy, in delivery rooms (1st stage), in the coronary care, in the burn unit and acute respiratory care; in England, in the intensive care unit; in Australia, in the neonatology intensive care unit, in the coronary care on day shifts, in case of high dependency units; in Canada, post-anesthesia units in case of conscious (waking) patients, in intensive care, in dialysis departments. In the USA, a nurse:patient ratio of 1:3 is recommended in ante/post partum departments, in labour room, in pediatrics, in the emergency department, in telemetry units, in „step down” units (subintensive); in England, in emergency departments, in pediatrics (under the age of 2); in Australia, in the emergency departments, and a further 1-1 triage nurses in the morning and at night are also needed as well as 2 triage nurses in the afternoons, and a shift manager in every shift, in the coronary units during night shifts; in Canada, in the emergency departments, at the telemetry units in „step down” units (subintensive). In the USA, a nurse:patient ratio of 1:4 is recommended in Surgical/Internal Medicine departments, in other special care units, in psychiatric departments; in England, in the Surgical/Internal Medicine departments, in pediatrics (above the age of 2 in day shifts); in Australia, in the ante/postpartum departments (in day shifts), in Surgical/Internal Medicine departments (in day shifts in case of Level I. hospitals, in the mornings in case of Level II. hospitals); in Canada, in the ante/postpartum departments, in pediatrics, in Surgical/Internal Medicine departments. In the USA, a nurse:patient ratio of 1:5 is recommended in the Surgical/Internal Medicine departments (at night in case of California), in rehabilitation departments, in case of a „skilled nursing facility”; in England, in pediatrics (above the age of 2 in night shifts), in case of nursing departments (but no more, than 1:7), in case of nursing homes (in mornings); in Australia, in the Surgical/Internal Medicine departments (afternoons in case of Level II. hospitals, mornings in case of Level III hospitals); in rehabilitation departments (in mornings and afternoons). In the USA, a nurse: patient ratio of 1:6 is recommended in the newborn unit and the psychiatric department (California); in England, in case of nursing homes (afternoons); in Australia, in the ante/postpartum departments (in night shift), Surgical/Internal Medicine departments (afternoons in case of Level III. hospitals). In Australia, a nurse:patient ratio of 1:7 is recommended in case of aged care wards (mornings). In England, a nurse:patient ratio of 1:8 is recommended in case of Surgical/Internal Medicine departments in night shifts; in Australia, in case of aged care wards (afternoons), in case of Surgical/Internal Medicine departments (at night in case of Level I-II. hospitals). In England, a nurse: patient ratio of 1:10 is recommended in case of nursing homes (at night); in Australia, in rehabilitation departments (in night shift), and in case of Surgical/Internal Medicine departments (at night in case of Level III. hospitals). In Australia, a nurse: patient ratio of 1:15 is recommended in case of elderly care wards (at nights).54, 55, 56, 57, 58, 59, 60
Based on research, it can be assessed that a strong correlation is shown between the number of daily nursing hours to one patient and “nursing-sensitive” rates as falls, pneumonia acquired in hospitals, upper-gastrointestinal hemorrhages, shock/heart failure, decubitus (in case of surgery patients) and urinary tract infections (in case of surgery patients). The research of Kane and his colleagues highlighted the fact that the likelihood of mortality related to hospital care can decrease by 9-16% by every additionally employed nurse.61, 62
A strong correlation is shown between the above statements and the statements expressed in point II.6. on the correlations between the nursing staff and infections related to health care services –regarding the significance of the subject. Nurses feel overworked. In order to examine the workload, we need to examine the changes in the past years’ professional minimum conditions. In 2001, the 1996 order was still in effect, prescribing 21 nurses for a 40-bed internal medicine department, while the 2003 modified order prescribed only 13 nurses for the same internal medicine department. The minimum order truly prescribes the minimum, however, it is an open fact that economists do not always allow a deviation upward from this order, in order to decrease institutional costs. Therefore, we are forced to treat patients with greater nursing demands with a smaller number of nurses. Unfortunately, the health status of the population is worsening, the population is aging, multimorbid patients check in with high-level nursing demands, and the expectations regarding treatment increased as well. These social challenges are needed to be met with a decreasing number of nurses. Due to the occurring discontent, exhaustion, the low salaries, the alternating work schedules and the lack of societal- and professional recognition, the present well-educated workforce is also leaving the field.
The infections related to health care services are among the most common, preventable complications, which affect hospitalized patients, endangering their safety. Despite the efforts made, the load of the infections related to the European health care services is high, and causes an approximate of 37000 deaths annually. The infections related to health care affect millions of patients worldwide, the number of infections related to health care services in the European Union only is 4544100 and it increases hospital stay by several days in 16 million cases.
The occurrence of infections related to health care services depends on several factors. In one study, during the evaluation of professional publications published between 1996 and 2012, 10 key components were identified. These are the hospital hygiene control, the utilization of beds, the employment of staff, the work load, the employment of nurses; the access to material and equipment, the suitable utilization of guidelines. The suitable education of health care workers is also a factor. These all can be associated with infections related to health care services, and if we improve upon these factors, the frequency of such infections can be decreased and patient safety can be improved.63 According to one survey in which the knowledge of educated, practicing nurses was examined regarding infections related to health care services, the majority of the nurses (87%) possessed “sufficient” knowledge, while only 4% possessed well-rounded knowledge regarding the preventive actions for infections related to health care services.64
The hospital staff is one of the provable key factors correlating with infections. The ratio between nurses and patients is not only an important tool for measuring the quality and the work conditions, it is a factor affecting the quality of the nursing and the recovery of the patients as well. According to empirical studies, the number of staff – among others – affects the risk of infections as well as the deaths due to complications recognized too late.65 A further reason for increasing concern is that the changes within the nursing workforce and the structural changes in hospitals have a negative effect on the patients. Several studies have indicated that overcrowding, underemployment or the lack of balance between workload and resources are all major factors regarding the determination of infections and the occurrence of micro-organisms related to health care services. It is also important to note that not only the number of staff, the educational level also has an effect on the results. The connection between underemployment and infections are complex, the lack of time may also be a determinant – which results in the recommendations for preventing infections are not completed –, as well as unemployment, workplace burnout, absenteeism and the high staff reduction. Several international studies researched the effect of different nursing models on the costs of care, the adverse effects on patients and the occurrence of wound- and urinary tract infections. Based on examinations conducted in several teaching hospitals, it can be stated that the lower the number of the employed educated nursing staff in a given unit, the higher the number of different occurring infections. In the study conducted in the Canadian Ontario 19 teaching hospital, the correlation between different nursing staff models and the occurrence of complications was examined. The models were grouped as follows: 1) RN/RPN (Degree Nurse/Practical Nurse) nurses, 2) only RN, 3) regulated and non-regulated staff (URW- nurses providing health care services not in clinical employment, 4) RN/RPN/URW combination. In internal medicine-, surgical- and obstetric departments, where the number of professionally educated nurses was lower, or the number of experienced nurses was lower, the rate of wound infections was higher.66
In the study of the University of Columbia associates, the correlation between the Degree nurse (RN), Licenced Practice Nurse (LPN) and Nurse Assistant (NA) workforce and the infections related to health care services were examined in retirement homes. While in the case where the elderly were cared for by an RN year by year, the incidence of infections decreased by 3.8%-, in the case of LPN nurses, this decrease was at a rate of 2%. In case of RN nurses, it was shown that less infection cases occurred for 1000 residents by 38.67 They have researched the correlations between care by nurses with different qualifications (RN, LPN, NA) working in internal medicine and surgical departments and the occurrence of complications. The number of RN nurses is in correlation with the decrease of the length of hospital stays, and the number of RN nurses and the nursing hours conducted by them decreases the incidence of urinary tract infections and pneumonia. The higher number of RN nurses working in surgical departments are also in correlation of the decreasing rate of urinary tract infections (UTI).68 If the number of Certified Nurses is increased by only 1 person, the infection rate can be decreased by a value of 0,19. The number of nurses with higher degree qualification increases patient safety and promotes high quality care.69 An Australian study was expressly examining the effect of nursing assistants on the occurrence of complications. According to the results, a significant correlation can be shown between care by nursing assistants and the occurrence of urinary tract infections. In case the patients spent 10% more time in the care of assistants, the chance of UTI occurrence was increased by 1%, while the chance of pneumonia occurrence was increased by 2%. In departments, where assistants were in a bigger percentage, a 10% extra time spent resulted in a 3% increase of UTI development, while the chances of the occurrence of sepsis was increased by 1%.70
In a synthesis study, 35 professional publications published between 2006 and 2017 were examined. It was determined that a higher number of nurses decreased the risk of inhospitalis mortality by 14%. Furthermore, it was determined that in departments with a greater number of nurses, the outcome of illnesses was better as well.71 Examining the correlation between infection complications related to health care services following surgery and the number of RN nurses, a significant correlation was determined between UTI as well as pneumonia and RN nurses working full-time. If the treatment time conducted by RN nurses is increased by only 30 minutes, the occurrence of UTI would be 0,16 regarding 100 surgical cases. With an equivalent of RN treatment time, the occurrence of pneumonia was lower by 4.2%.15 Examining the data of 124 thousand patients, similar results were published, as in if the patient care time of RN nurses were to be increased by 1 hours for every sick day, the chances of pneumonia-occurrence would decrease by 8.9%, and the 10% increase of RN nurse numbers participating in treatment would decrease the chances of complication-occurrence by 9.5%.72 In Great Britain, the data of 137 hospitals were analyzed for two years (2009-2011) regarding the number of nurses/number of patients, in which it was determined that if a general ≤ 6 patients are provided for every (RN) nurse, the mortality rate was 20% lower than in the case of > 10 or more number of patients were provided for one nurse.73 In a Swiss study conducted in an intensive internal medicine department, patients staying in the department for more than 7 days were examined. The daily median number of the nurse-patient ratio for the examined period was 1.9. As a result, it was shown that the risk of infection-occurrence with a ratio above of this nurse-patient ratio was nearly two times higher.74
In every year, near 7 million hospitalized patients are infected during the treatment of other illnesses. In a 2012 study, urinary tract- and surgical infections were examined, which are the most common infections, possibly occurring at any hospital units. There was a significant correlation between the nurse-patient ratio and urinary tract- and surgical infections. Controlling the severity of the patient’s status and the nurse and hospital characteristics in a multivariate model, it was assessed that the burnout affecting the nursing staff is significantly correlated with urinary tract- and wound infections. In hospitals where burnout was decreased by 30%, the number of total infections were lower by 6393 (an even 29% lower UTI and 74% lower wound infection-occurrence), which may result in an annual cost-saving of 68 million USD. The decrease of the burnout of degree nurses is a promising strategy for the management of infections occurring within acute treatment institutions.14
It is important at the determination of the range of nursing equipment that will be purchased in the future that nursing researchers/ developers are also able to participate, who are able to adapt international practices into the national practices, and able to develop a strategic development concept, in addition to our nursing leaders representing recent practice. As an example, the acquisition of smart nursing equipment should be highlighted (which in most cases is not a material issue but a question of attitude) and the record of data received by the devices via wireless communication within the EESZT, in the electronic nursing documentation. (For more details, see Section II.4.) Providing the adequate occupational / protective clothing is importantin, also in accordance with international examples, vocational/Bachelor/ Master nurses should have different occupational clothes per level of education.
Transitional Care (TC) is a specialized treatment field for patients who require more than the provision of the acute hospital sources, yet they still require a 24-hour medical-, nursing-, or other health care services during their recovery or rehabilitation. The aim of this treatment form is the decrease of possible readmission, the maximizing of patients’ independence, providing individual- and group education for patients and their relatives, to provide consultation, and to assess and promote the needs of patients. Patients utilizing TC care stay in the institution for an average of 5-30 days. The patients mainly require the following services: cardiological rehabilitation, rehabilitation following surgery, oncologic and pain management, pulmonary care, complex wound treatment, complex medical treatment. Based on the statistics, in the USA, an approximate of 3.3 million patients required readmission within 30 days in 2011, resulting in a total cost of 41 billion dollars. In one of the studies conducted by the Cleveland Clinic, the effects of the work of Advanced Practice Nurses with a Master’s degree and temporary care on rehospitalization was examined. During the intervention phase, adjusted 30-day readmission rates declined from 28.1% to 21.7%. The absolute reductions ranged from 4.6% for patients at low risk for readmission to 9.1% for patients at high risk. The task of a Master level nurse – with the aid of the health care- and social system – is the maintenance of the individual’s health, the minimizing of the effect of illnesses, the coordination of complex therapeutic regulations, and the cooperation with physicians and relatives. Studies show that this treatment model improves the satisfaction of older adults, decreases the resumption of treatment and decreases the costs of health care services. In the case of patients, who have undergone an unplanned caesarean section, the hospital budget was decreased by 22%, in case of treatment of high risk pregnancies, it was decreased by 39%, and in the case of treating patients who underwent hysterectomy, the decrease was 6%. In case of care controlled by advanced practice Master’s, the degree of rehospitalization was lower in one year following discharge and 5000 USD was saved for every patient.75, 76, 77
According to Hungarian legislation, a Nursing Care Department and a Nursing Care Institute can be established, however, in order for them to operate as actual structure-transformative elements, profession policy support and the elevation to policy program-level is necessary. The home nursing services - as existing and financed structures - require correction, as the legislation in force makes difficult to provide services and equal opportunities for patients, does not provide opportunity for need-based care, and disproportionately neglects nursing tasks (eg. physiotherapy takes on priority status), mostly certain nursing tasks (eg. wound care) outside home care frameworks, due to lack of nursing education, limited visit frameworks, insufficient funding and lack of human resources.
In addition to the tasks set out in the National Economy’s 20/1996. (VII.26.) Decree, there are several other tasks that need to be introduced in Hungary in the case of home care internationally: drug infusion therapy (eg. chemotherapy, antibiotics, analgesia), transfusion therapy, peritoneal dialysis, diabetes management, bowel and bladder training, suture removal, sampling (eg. blood, stool, urine, sputum), client education.
The question of the employment of nurses, professional nurses, physiotherapists, and speech therapists working in professional home care and rehabilitation, who cause hospital care should be also a priority. As a starting point, we recommend to increase the amount of the visit fee adusted to the percentage of wage increase of health professionals, because without the increase of the visit fee the service providers cannot settle the wages.
In additionto to this segment, it would also be important to have a payroll option where qualifications are taken into account, making the area more competitive with workplaces which have the same qualification requirements.
Although, in a significant part of the Strategy we used evidences from acute care to demonstrate that the appropriate proportion of Bachelor nurses in the acute care system significantly reduces the risk of of patients’ health damage (serious side effects) or death, but we should not be forgotten about chroonic care. Harrington et al. indicated in 2016 that 33% of those patients who were treated in nursing homes of the American State Health Care System (Medicare) had unexpected serious side effects and these’s final outcome was health damage or even death, during the first 35 days of relocation from hospital post-acute status to nursing home. In 2011 in Medicare there were 2.5 million hospital relocations to nursing homes, which costed 28 billion USD. During the examination of the Rivising Chief Medical Office, in the background of 60% of serious side effects was under-care, inadequate monitoring, delays or mistakes in care, which additionally totally costed 2.8 billion USD. Referring to another study, it is mentioned that in 2011, 25% of nursing home patients were re-admitted to hospitals with problems that could have been prevented. We can see that the framework and quality of organizing chronic care has a strategic importance regarding cost-effectiveness in active care and health care, that is the reason we do not support the transfer of chronic beds to the social sector. Also due to the fact that the required qualifications are different, caring and nursing is different and the professional content of care is different. There are no similar data available in Hungary on the inadequate nurse: patient ratio in the field of chronic care, and on the level of acute care due to the lack of nurses with an adequate certification is currently unavailable. If this data becomes even closely to approximate, the Bachelor nurses’ implication to the system will be compensated by the fact that these nurses will be able to eliminate a significant portion of unnecessary acute hospital admission.78