Countries with High Registered Nurse (RN) Concentrations Observe Reduced Mortality Rates of Coronavirus Disease 2019 (COVID-19)

Abstract

Background:

The novel coronavirus disease 2019 (COVID-19) pandemic has generated many questions on its screening, diagnosis and management. One important question emerging from this discussion of regional differences pertains to the healthcare workforce not just in absolute numbers but also in terms of skill-mix. As nurses comprise over half the skilled healthcare workforce worldwide, it is important to consider them as part of a health systems strengthening approach to quality improvement. We sought to investigate the influence of the registered nurse (RN) concentration and the impact on COVID-19 mortality between countries worldwide.

Methods:

We conducted an observational cohort study to examine the association between COVID-19 mortality rates and concentrations of registered nurses. Data on nursing concentrations by country provided from the World Health Organization were merged with March 2020 COVID-19 mortality rates. Descriptive statistics, geographical information systems (GIS) mapping and multilevel linear regression with mixed effects were applied to examine this association with regional clustering of countries.

Findings:

In total, 172 countries were included in the analysis. These results indicated that for every 1.0 increases in RN per 1,000 individuals in a country, there was a decrease in COVID-19 mortality of −1.98 per 1 million individuals (p=0.003).

Interpretation:

High nursing concentrations are strongly associated with reduced mortality rates of COVID-19. The key to address the needs of current and future COVID-19 outbreaks, or for that matter, any infectious disease outbreak of this magnitude is to prepare a highly trained, versatile nursing workforce.

INTRODUCTION

The novel coronavirus disease 2019 (COVID-19) pandemic has generated many questions on its screening, diagnosis and management.¹ Patterns of disease hotspots, in particular, have led to speculation on spread, management and impact of the virus. Regional variations across the globe have been attributed to different strategies for mitigation and containment.² Moreover, disease spread may be explained by public health approaches, healthcare system organization as well as funding and governance models.³

One important question emerging from this discussion of regional differences pertains to the healthcare workforce not just in absolute numbers but also in terms of skill-mix. In Germany, for instance, the case fatality rate is lower than other countries; a recent CNN report made an interesting observation that among many factors, including level of testing and the availability of intensive care beds that could explain this observation was the number of nurses.⁴ Germany has 13.2 nurses per 1,000, make it among one of the highest workforce concentrations in the world. The World Health Organisation (WHO) State of the World’s Nursing Report to be released this month will provide a technical description of the global nursing workforce and actions necessary to achieve universal health coverage and the Sustainable Development Goals.⁵ Several studies have demonstrated improved outcomes associated with higher levels of nursing education but these have been primarily confined to acute care or academic medicine.^6,7 On a global level, explaining the value and impact of nursing to health and well-being is often inferred but not directly related challenging evidence-based policy and investment.⁸ Previous outbreaks of infectious diseases have underscored the fragility of health systems and the importance of agile, robust health systems.⁹ As nurses comprise over half the skilled healthcare workforce worldwide, it is important to consider them as part of a health systems strengthening approach to quality improvement.¹⁰

The spread of the COVID-19 pandemic has generated some real-time data sets providing a window for analysis and comparability.¹¹ We sought to investigate the influence of the registered nurse (RN) concentration and the impact on COVID-19 mortality between countries worldwide.

METHODS

Study Design

We obtained the most recent data on an observational cohort of national concentrations of RNs in order to explore the presumptive correlation between RN availability and COVID-19 mortality rates. Data on COVID-19 mortality were obtained from Johns Hopkins Coronavirus Resource Center (https://coronavirus.jhu.edu/map.html, Baltimore, USA) based on resulting rates reported as of March 30, 2020. COVID-19 mortality rates were expressed in terms of cases per 1 million people in each nation’s population. These data were merged with most current data on the rates of RNs per 1,000 people in each nation’s population, according to the World Health Organisation (WHO) Global Health Workforce Statistics (https://data.worldbank.org/indicator/sh.med.numw.p3, Geneva, Switzerland).

Data

Data regarding RN concentrations from the WHO were reported by countries in the timeframe of 2009 through 2018. Not all national data on RN concentrations were current. When a nation did not provide data on RN concentrations as of 2018, we obtained the next most-current year of data available, which in some cases dated as far back as 2009.

While many data elements are currently available regarding the global outbreak of COVID-19, we chose to exclusively collect mortality rates for analysis. COVID-19 infection rates would be important data to place in this analysis, but infection rates are biased by the current availability of diagnostic testing kits, of which there is a reported international shortage.¹² Given this bias, mortality data provide a more consistent estimate of the extent of burden that COVID-19 is having on public health efforts globally and the influence of nursing, particularly in acute care.

Merged data between 2020 COVID-19 mortality rates and most recently reported RN concentrations were clustered by global region. There were 15 global regions specified in the analysis to explore between- and with-region effects of RN availability on mortality. Clustering was assumed for two primary reasons: (i) that RN resources are mobile at the regional level, as observed in Western and Central Europe to address outbreaks in places including Italy and Spain; (2) limited global travel combined individual interactions between neighboring countries within a region has impacted the spread of COVID-10 and related mortality rates.¹³

Analysis

Descriptive statistics were extracted from the Johns Hopkins Coronavirus Resource Center and the WHO in order to provide an overview of mortality rates and RN concentrations by global region. We also conducted geographic information system (GIS) mapping in order to illustrate the additive impact on nursing on COVID-19 mortality rates. On a world map, we provided country-specific information on the outcome: COVID-19 Deaths per 1,000 Population per RN.

Multilevel regression analysis was undertaken with mixed-effects to study the association between RN concentrations and COVID-19 mortality rates at the national-level (j), clustered by global region (i). For this analysis fixed-effects and random-effects versions of linear regression models were tested on this association. Random-effects controlled for in the regression analyses included both a random-intercept (u_i0) and random-slope (u_i1) corresponding to RN concentrations.

$$Mortalit{y}_{ij}=\left({\beta }_{\mathit{0}}+u_{i\mathit{0}}\right)+\left({\beta }_{\mathit{1}}+u_{i\mathit{1}}\right)RNrat{e}_{ij}+{\epsilon }_{ij}$$ (Equation 1)

We conducted a likelihood ratio test to accept or reject the random-effects version of the model with regional clustering in favor of a fixed-effects model. We improved fit of the random-effects models by exploring the covariance structure of the data and specifying appropriate structure as-needed. We regressed models over seven quadrature points.

RESULTS

In total, 172 countries were included in the analysis if they reported current rates of COVID-19 mortality or RN concentrations (Table 1). Clustering countries by global region provided some valuable information to study the associations between RN concentrations and mortality rates. While Western Europe had some of the highest concentrations of RNs, it also has some of the highest mortality rates due to concentrated outbreaks in certain countries (e.g. Italy, Spain, etc.). On the other hand, isolated countries such as in Central and West Africa had both low concentrations of nursing and low reported mortality rates (Figure 1).

Table 1.

Summary statistics on national rates of registered nurses and mortality rates related to Coronavirus Disease 2019 (COVID-19) as of March 30, 2020, clustered by designated global regions.

		RN per 1,000 Population		Deaths per 1 million Population
Countries (by region)	N	Mean	SD	Mean	SD
Total	172	4.15	4.01	8.39	26.26
Western Europe	20	10.91	4.32	42.79	53.59
Eastern Europe	25	7.01	2.59	2.44	2.02
Western Asia	8	3.27	2.86	5.63	13.41
Middle East	13	3.96	1.82	1.06	0.84
East Asia	5	4.99	3.76	1.80	1.31
Southeast Asia	16	2.47	2.37	0.54	0.64
North Africa	5	2.82	2.28	0.73	0.22
West Africa	14	0.87	0.52	0.42	0.62
Central Africa	16	0.77	0.65	0.13	0.15
Southern Africa	10	1.92	1.31	0.55	0.97
Australia, New Zealand, & Pacific Is.	4	6.77	5.94	0.45	0.35
North America	2	9.23	0.96	6.00	5.66
Central America	8	1.55	0.72	1.26	2.33
South America	12	1.97	2.51	0.80	1.09
Caribbean	14	3.27	2.05	4.34	6.15

Figure 1.

Global map of Corona Virus Disease 2019 (COVID-19) related mortality rates per 1,000 population per Registered Nurse (RN) as of March 30, 2020.

A multilevel regression model provided best-fit results analyzing the association between COVID-19 mortality and RN concentrations, clustered by global region (Table 2). These results indicated that for every 1.0 increases in RN per 1,000 individuals in a country, there was a decrease in COVID-19 mortality of −1.98 per 1 million individuals (p=0.003). While there were statistically significant effects of regional clustering (p<0.001), RN concentration effects between regions did not provide statistically significant improvements (p>0.05). Thus, the final reported regression model of this study was a random-intercept approach with independent correlation between regions.

Table 2.

Multilevel regression model of association between registered nurse concentrations and mortality rates related to Coronavirus Disease 2019 (COVID-19) by country, clustered by global region.

				95% Confidence Interval
Deaths per 1 Million Population	Coefficient	SD	P-value	Lower	Upper
RNs per 1,000 Population	−1.987	0.659	0.003	−3.279	−0.694
Intercept	13.799	5.460	0.011	3.098	24.500
Variance(Intercept)	245.621	120.504	<0.001	93.899	642.498

Log-Likelihood= −528.73

DISCUSSION

Our analysis has shown that high RN concentrations are associated with significant reductions in COVID-19 mortality rates across the globe. Increasing the concentration of nursing workforce by 1.0 RN per 1,000 results in nearly a −2.0 per million reduction in COVID-19 related mortality. These data offer critical insights into the importance of the healthcare workforce, and RNs in particular to manage surges in patient volume caused by an infectious disease outbreak.

Countries dealing with the COVID-19 outbreak need to act quickly to minimize the spread of infection as well as prevent further mortality. We recognise that the spread to Africa and other low resource areas is a major concern.¹⁴ The availability of RNs is an important component of managing the complex issues associated with a pandemic. Countries facing volume surges concomitant with RN shortages need to consider strategic alliances with other nations in a region that may be able to provide additional nursing resources or augment strategically with other roles. Other countries that have not yet faced a volume surge, or reached the apex of the current COVID-19 outbreak should consider decisive action in order to prevent future deaths by activating all available nursing workforce in order to anticipate future surges.

Existing evidence on COVID-19 with respect to previous coronavirus outbreaks implies that this virus could be seasonal as well as recurring. Now is the time to invest in nursing education at all levels of available, willing citizens in order to cope with national, regional, and international concerns regarding future outbreaks of COVID-19. Baccalaureate prepared RNs require college-level education in an approved institution. Some of this education can be expedited in the next 6–12 months in order to prepare nurses for the front-lines. Certified nursing assistants (CNA) can also augment under-staffed healthcare workforce with individuals who are able to execute basic nursing tasks in the short run in order build capacity for existing surges. In some surge areas, medical students are being deployed to undertake traditional nursing tasks particularly in intensive care units.

Limitations

This study has several limitations. First, the lack of currently available data on nursing concentrations for a number of countries in this study may bias the reporting of results since populations have grown world-wide in recent years, but rates of graduated nurses may remain relatively constant. However, if nurse concentrations are actually lower than this study represents, then nursing value could be even greater than estimated in this report given the rate-reductions in COVID-19 mortality are associated with fewer nurses than observed. Second, these estimates of COVID-19 outcomes are biased by national reporting from many countries. Without proper diagnostic testing availability, patient death caused by similar circumstances such as concomitant seasonal influenza with pneumonia suggest that there are probable deaths caused by other infections being misrepresented at COVID-19 deaths. Third, a lack of other reliable data, such as the current rates of COVID-19 infection, biased by diagnostic testing kit availability, limit the amount of variability in the regression model expressed by one key explanatory variable, RN concentrations. Fourth, these data provide only a glimpse into the value that skilled nursing provides for managing COVID-19 infection and reduced mortality. Extended durations of longitudinal data on mortality, including seasonal data will provide a more informed story about these associations in the future.

Conclusions

In conclusion, high nursing concentrations are strongly associated with reduced mortality rates of COVID-19. As other data on COVID-19 become more readily available and reliable to analyze, these results could change, particularly as new waves emerge. In general, the key to address the needs of current and future COVID-19 outbreaks, or for that matter, any infectious disease outbreak of this magnitude is to prepare a highly trained, versatile nursing workforce. Data in this study illustrate not only the quantity of nursing that leads to better outcome, but the value that nurses provide on both national and regional levels.

PANEL: RESEARCH IN CONTEXT.

Evidence Before This Study:

The novel coronavirus disease 2019 (COVID-19) pandemic has generated many questions on its screening, diagnosis and management. Disease spread across global regions may be explained by public health approaches, healthcare system organization as well as funding and governance models. One important question emerging from this discussion of regional differences pertains to the healthcare workforce not just in absolute numbers but also in terms of skill-mix. In Germany, for instance, the case fatality rate is lower than other countries, and among many factors, including level of testing and the availability of intensive care beds that could explain this observation was the number of nurses. As nurses comprise over half the skilled healthcare workforce worldwide, it is important to consider them as part of a health systems strengthening approach to quality improvement. We sought to investigate the influence of the registered nurse (RN) concentration and the impact on COVID-19 mortality between countries worldwide.

Added Value of This Study:

This study combines nation-specific COVID-19 mortality rates with nursing concentrations to determine the association between skilled nursing and outcomes during major pandemics. We determined that each additional 1.0 nurses per 1,000 is associated with a statistically significant −2.0 decrease in COVID-19 mortality per 1 million.

Implications of All This Available Evidence:

High nursing concentrations are strongly associated with reduced mortality rates of COVID-19. The key to address the needs of current and future COVID-19 outbreaks, or for that matter, any infectious disease outbreak of this magnitude is to prepare a highly trained, versatile nursing workforce. Data in this study illustrate not only the quantity of nursing that leads to better outcome, but the value that nurses provide on both national and regional levels.