ICU nurses with more experience, education cut inpatient mortality

Registered nurses remain the largest group of health care providers and typically account for the greatest expense (approximately 60 percent) in most operating budgets. Previous research in adult hospitals has shown the positive effect of the increasing percentages of nurses with baccalaureate educations is consistent across all U.S.hospitals.

However, this same assessment has not been conducted in children’s hospitals—until now.

In a recent study, nursing leaders from 38 children’s hospitals, led by Patricia Hickey, PhD, MBA, RN, from the Heart Center at Boston Children’s Hospital, conducted a study to explore pediatric critical care nursing and organizational characteristics that impact in-hospital mortality for congenital heart surgery patients across children’s hospitals in the U.S. The study, published in the Journal of Nursing Administration, assessed this impact on 20,407 pediatric patients. In pediatrics, congenital heart disease is the most commonly occurring birth defect requiring surgical intervention for survival and consuming a principal share of hospital resources. “The hardest challenge is getting this right—and improving mortality rates—for the sickest patients,” says Hickey.

Of the nurses studied, 71 percent held a baccalaureate degree in nursing. The distribution of nursing experience included 52 percent of the nurses having five or less years of nursing experience. Also, 62 percent of the nurses had five or less years of nursing experience in the intensive care unit (ICU). Fifteen percent of the pediatric nurses were professionally certified in critical care (13 percent) or pediatric nursing (2 percent).

Years of nursing experience was significantly associated with improved patient outcomes and independently associated with in-hospital mortality.

In critical care units, a cut-point of 20 percent appears to be the critical value at which the percentage of RNs with two years or less of clinical experience significantly increases the odds of death. When more than 25 percent of nurses have two or less years of experience, the odds of in-hospital mortality increases by a factor of 1.52.

Importantly, years of ICU experience alone was not a predictor of mortality, but total clinical experience was a significant factor. “This finding may reinforce the notion that experiential knowledge and skill acquisition is cumulative over time regardless of the clinical setting,” the authors wrote.

The odds of in-patient mortality lessened when there was a higher institutional percentage of critical care nurses with clinical experience of 11 years or more and for hospitals participating in national quality metric benchmarking.

Based on their findings, the authors of this study recommended that pediatric ICU should not have more than 20 percent of their staff with less than two years’ experience.

“We believe ongoing attention to the proportional mix of experience level of pediatric critical care nurses needs careful scrutiny by unit and hospital leadership,” Hickey notes.

However, she stresses the importance of bringing on new graduate nurses into these units, as long as they are appropriately supported through orientation and mentorship for two years. “We are obligated for the future of pediatric critical care to have a pipeline of properly experienced, educated nurses. The study also reinforces the need for retention strategies.”

Future research is required to determine other pediatric nursing and organizational factors that may have a protective effect on mortality for critically ill patients.