Associations between nurse education and experience and the risk of mortality and adverse events in acute care hospitals: A systematic review of observational studies

Objectives: To provide knowledge from the summarization of the evidence on the: a) associations between nurse education and experience and the occurrence of mortality and adverse events in acute care hospitals, and; b) benefits to patients and organizations of the recent Institute of Medicine's recommendation that 80% of registered nurses should be educated at the baccalaureate degree by 2020. Data sources: A systematic search of English and French literature was conducted in six electronic databases: 1) Medline, 2) PubMed, 3) CINAHL, 4) Scopus, 5) Campbell, and 6) Cochrane databases. Additional studies were identified by searching bibliographies, prior reviews, and by contacting authors. Review method: Studies were included if they: a) were published between January 1996 and August 2017; b) were based on a quantitative research design; c) examined the associations between registered nurse education or experience and at least one independently measured adverse event, and; d) were conducted in an adult acute care setting. Data were independently extracted, analysed, and synthesized by two authors and discrepancies were resolved by consensus. The methodological heterogeneity of the reviewed studies precluded the use of meta-analysis techniques. However, the methodological quality of each study was assessed using the STROBE criteria. Findings: Among 2109 retrieved articles, 27 studies (24 cross-sectional and three longitudinal studies) met our inclusion criteria. These studies examined 18 distinct adverse events, with mortality and failure to rescue being the most frequently investigated events. Overall, higher levels of education were associated with lower risks of failure to rescue and mortality in 75% and 61.1% of the reviewed studies pertaining to these adverse events, respectively. Nurse education was inconsistently related to the occurrence of the other events, which were the focus of only a small number of studies. Only one study examined the 80% threshold proposed by the Institute of Medicine and found evidence that it is associated with lower odds of hospital readmission and shorter lengths of stay, but unrelated to mortality. Nurse experience was inconsistently related to adverse event occurrence. Conclusion. While evidence suggests that higher nurse education is associated with lower risks of mortality and failure to rescue, longitudinal studies are needed to better ascertain these associations and determine the specific thresholds that minimize risks. Further studies are needed to better document the association of nurse education and experience with other nursing-sensitive adverse events, as well as the benefits to patients and organizations of the Institute of Medicine's recommendation.