USP Origial Article DOI: 10.1590/S0080-623420150000800007 Nursig staff i the iteral medicie ad surgical uits of teachig hospitals: compositio ad cost Quadro de profissioais de efermagem em uidades médico-cirúrgicas de hospitais de esio: composição e custos Cuadro de los profesioales de efermería e las uidades médico-quirúrgicas de los hospitales de eseñaza: composició y costos Ferada Maria Togeiro Fuguli 1, Atôio Ferades Costa Lima 1, Valéria Castilho 1, Carolie Pereira Guimarães 2, Ariae Carvalho 3, Raquel Rapoe Gaidziski 4 1 Associate Professor, Departmet of Professioal Guidace, School of Nursig, Uiversity of São Paulo, São Paulo, SP, Brazil. 2 Master s Studet i Scieces, School of Nursig, Uiversity of São Paulo, São Paulo, Brazil. 3 Nurse, School of Nursig, Uiversity of São Paulo, São Paulo, Brazil. 4 Full Professor, Departmet of Professioal Guidace, School of Nursig, Uiversity of São Paulo, São Paulo, SP, Brazil. ABSTRACT Objective: Evaluate the mea quatitative ad qualitative ursig staff workig i the iteral medicie ad surgical uits of three public geeral teachig hospitals i the city of São Paulo, compared to projected mea staff accordig to the parameters of Cofe Resolutio No. 293/04, as well as measure the mea cost of curret ad projected ursig staff. Method: Quatitative, descriptive, exploratory study usig prospective data collectio. Results: I most of the uits studied, the umber of ursig professioals was adequate. I two of the istitutios, the percetage of urses was lower tha that recommeded by Cofe. Qualitative ad quatitative adjustmet of the staff would represet a mothly cost icrease of R$141,326 for Hospital A, R$138,989 for Hospital B, ad a reductio of R$99,028 for Hospital C. Coclusio: The mai cotributio of this study was the proposed method for qualitative ad quatitative evaluatio of ursig staff, i additio to determiig the average cost for adjustmets. DESCRIPTORS Nursig; Hospital ursig staff; Workload; Cost ad Cost Aalysis. Correspodece Addressed to: Ferada Maria Togeiro Fuguli Av. Dr. Eéas de Carvalho Aguiar, 419 - Cerqueira César CEP 05403-000 São Paulo, SP, Brazil ffugulim@usp.br Received: 11/30/2014 Approved: 03/05/2015 Rev Esc Eferm USP 2015; 49(Esp2):47-53 47
Nursig staff i the iteral medicie ad surgical uits of teachig hospitals: compositio ad cost INTRODUCTION I recet decades, the social, political ad ecoomic ladscape has prompted the pursuit of maagemet strategies capable of recocilig budget costraits with improvemet of products ad services offered to populatios. Health istitutios also face the challege of efficiet use of resources while also improvig the service provided to their users. I Brazil, these istitutios are experiecig major hardships due to lack of ivestmet i ifrastructure ad the workforce, combied with the icreasig health eeds of the populatio. Problems related to maagemet ad traiig of huma resources are cosidered oe of the mai factors i deterioratio of health care services (1). The primary measures adopted by maagers i this sector i their efforts to tackle risig costs ofte result i quatitative ad qualitative limitatios i ursig staff, creatig work overloads that hider the orgaizatio ad executio of care processes ad stad i the way of promotig measures to ehace quality of care ad the safety of users ad care providers (2). The istitutios ofte fail to meet the miimum ursig staff parameters recommeded i Resolutio No. 293/04 of the Federal Coucil of Nursig (COFEN) (3). Kowledge eeds to be geerated to assist i the decisio-makig process ivolvig ursig staff adjustmets ad the costs they would etail, thereby helpig to guide huma resources policies ad trasform maagemet processes i health istitutios. From this perspective, this study sought to evaluate the mea quatitative ad qualitative ursig staff workig i the iteral medicie ad surgical uits of three public geeral teachig hospitals i the city of São Paulo, compared to the projected mea staff parameters recommeded i COFEN Resolutio No. 293/04, as well as measure the average cost of the ursig staff, both curret ad projected, as per this Resolutio. METHOD A quatitative, descriptive, exploratory study, utilizig prospective data collectio, coducted i the iteral medicie ad surgical uits of three public geeral teachig hospitals, referred to as Hospital A, Hospital B ad Hospital C, i the city of São Paulo. This study was approved by the Research Ethics Committees of the School of Nursig of Uiversity of São Paulo (Process No. 1110/2011). Two uits were aalyzed i Hospital A, three i Hospital B ad five i Hospital C. Data were collected betwee August 2012 ad July 2013. The study populatio cosisted of ursig professioals (urses ad ursig techicias/aides) ad patiets hospitalized i the selected iteral medicie ad surgical uits. Calculatio of the quatitative ad qualitative daily meas for professioals i the uits The daily mea of urses ad ursig techicias ad aides workig i the uits durig each moth of the period from August 2012 to July 2013 was calculated through the followig equatio: Q k = Q d=1 k(d) d Q k = daily mea umber of professioals from category k workig i the uit; d Q k(d) = sum of the daily umber of professioals from category k workig i the uits o d = 1, 2, 3... days of the sample, obtaied through the mothly work shift records; k = professioal category beig aalyzed (urse, ursig techicia or aide). Projectio of the quatitative ad qualitative daily mea of professioals eeded for the uits The followig calculatios were employed: Idetificatio of the daily mea umber of patiets accordig to the degree of ursig depedecy: The researchers, i partership with the ursig team providig the care, classified the patiets accordig to the degree of ursig depedecy, usig the patiet classificatio system (PCS) desiged by Fuguli (4). The mea umber of patiets accordig to type of care was calculated usig the equatio: j = TO L j 100 j = daily mea umber of patiets accordig to type of care j (miimum, itermediate, high depedecy, semi-itesive ad itesive); TO = mea mothly occupacy rate i the uits, from August 2012 to May 2013; L j = umber of beds, accordig to type of care j (miimum, itermediate, high depedecy, semi-itesive ad itesive). The calculatio of the mea recommeded daily workload of ursig professioals, accordig to COFEN Resolutio No. 293/04 11, was obtaied through the equatio: C j = j h j C j = mea daily workload accordig to type of care j (miimum, itermediate, high depedecy, semi-itesive ad itesive); = mea daily umber of patiets accordig to type of care j (miimum, itermediate, high depedecy, semi-itesive ad itesive); h j = mea recommeded daily hours of care accordig to COFEN Resolutio No. 293/04 (3) (miimum, 3.8 hours; itermediate, 5.6 hours; high depedecy ad semi-itesive, 9.4 hours; itesive, 17.9 hours). The calculatio of the mea umber of professioals accordig to category was obtaied by applyig the followig equatios: Q= j=1 C j t 48 Rev Esc Eferm USP 2015; 49(Esp2):47-53
Q = mea daily umber of ursig professioals required; j=1 C j = sum of the daily mea workloads accordig to types of care (miimum, itermediate, high-depedecy, semi-itesive ad itesive); t = daily workig hours. The umber of urses was calculated usig the proportio recommeded i COFEN Resolutio No. 293/04 (3) for this professioal category. Q ef =Q P ef Q téc/aux =Q (1-P ef ) Q ef = mea daily umber of urses; Q = mea daily umber of ursig techicias/aides; P ef = mea proportio of urses (miimum ad itermediate care, 33%, high-depedecy ad semi-itesive care, 42%, ad itesive care 52%); Q téc/aux = mea proportio of ursig techicias ad aides (miimum ad itermediate care, 66%, high-depedecy ad semi-itesive care, 58%, ad itesive care 48%). These calculatios eabled compariso of mea umber of curret urses ad ursig techicias/ aides with the projected umber for the iteral medicie ad surgical uits accordig to official parameters. Data o ursig staff costs came from the persoel departmets of the hospitals, which set spreadsheets with the mea payroll costs for urses ad ursig techicias/aides durig the study period. The spreadsheets cotaied records o the umber of professioals, base wages, social security paymets, bouses ad beefits, by fuctioal category. Aual wages were calculated by totalig wages, charges, beefits ad bouses; that was total was divided by the umber of professioals, by category, to obtai mothly wages. To determie the mothly mea hourly costs per category, the mothly mea wage was divided by the umber of hours worked, accordig to the cotracts for each hospital. The variace i the umber of projected professioals (NPP), accordig to the categories, i relatio to the umber of curret professioals (NCP), as well as the variace i the mothly wage costs for the projected team (MWC-PT) i relatio to the mothly wage costs for the curret team (MWC-CT) was calculated as follows (5) : Variace=(NPP/NCP-1) 100=% Variace=(MWC-PT/MWC-CT-1) 100=% Data aalysis The data was etered i electroic spreadsheets ad preseted i figures ad charts, usig measures of cetral tedecy. The test of sigificace betwee meas ad the Chi-square test were used, at a sigificace level of 5% to compare curret staff with projected staff. Persoel costs were aalyzed by descriptive statistics, usig the mothly wage mea by professioal category i Hospitals A, B ad C. The amouts are show i Brazilia reals. RESULTS Durig the period studied, patiets i the iteral medicie ad surgical uits of the three teachig hospitals were classified by the researchers accordig to the PCS of Fuguli, Gaidziski e Kurcgat (4). The mea daily umber of patiets was: 76 i Hospital A, 118 i B, ad 117 i Hospital C. The mea daily distributio of patiets accordig to the classificatio is show i Figure 1. (A) (B) 0.9 (C) 0.8 6.1 7.6 7.5 Itesive 27.7 45.9 36.5 35 29.8 Itermediate Semi-Itesive 42 27.2 44.1 Miimum High-depedecy Figure 1 - Mea daily umber of patiets accordig to the patiet classificatio system from August 2012 to July 2013 - São Paulo, 2014. Figure 1 shows that i Hospital A there was a predomiace of patiets classified as eedig itermediate ad high-depedecy care, with o semi-itesive or itesive care patiets. I Hospital B, the largest umber of patiets was i the miimum care category, followed by high-depedecy ad itermediate care. I Hospital C, the itermediate care category had the largest umber of patiets, followed by miimum ad high-depedecy care. Hospitals B ad C allocated, o average, oe itesive care patiet ad seve semi-itesive care patiets per day i the uits studied. Figure 2 shows mea curret daily ursig staff ad projected staff for the same uits, i accordace with Cofe Resolutio. 294/04 (3). I the two uits from Hospital A, there was o sigificat differece betwee projected teams ad curret teams, usig the Cofe method, demostratig adequate umbers for the curret ursig staff. Rev Esc Eferm USP 2015; 49(Esp2):47-53 49
Nursig staff i the iteral medicie ad surgical uits of teachig hospitals: compositio ad cost 0 A B C Hospitals Figure 2 - Mea daily curret ad projected ursig staff, i the iteral medicie ad surgical uits of the three teachig hospitals, from August 2012 to July 2013 - São Paulo, 2014. I Hospital B, there was a sigificat differece i oly oe uit betwee projected teams ad curret teams usig the Cofe method, demostratig a shortage i the curret ursig staff. I the other two uits this differece was ot sigificat, idicatig a adequate umber of professioals. I Hospital C, there was a sigificat differece i oly two of the five uits studied betwee projected teams ad curret teams usig the Cofe method, demostratig that i these uits the curret umbers of professioals exceeded the projected umbers. I the other uits, where the differece betwee projected ad curret staff was ot sigificat, the umber of professioals was adequate. Figure 3 presets the mea daily distributio of professioals, accordig to category, curretly workig i the uits of the hospitals studied ad the projected percetages established by Cofe, takig ito accout workload ad predomiat type of care. Team Team 120 100 80 60 40 20 0 160 140 120 100 80 60 40 20 78 30 Curret Projected 86 17 15 Curret urses Projected urses 61 56 113 148 126 124 53 46 45 Figure 3 - Mea daily curret ad projected ursig staff by professioal category from August 2012 to July 2013 - São Paulo, 2014. 98 95 80 79 A B C Curret techicias/aides Projected techicias/aides Hospitals I the two uits studied i Hospital A, there was a sigificat differece betwee the projected umber of urses ad the curret umber of ursig, usig the Cofe method, idicatig that the umber of urses was lower tha the proportio recommeded by Cofe. I all the uits from Hospital B, there was a sigificat differece betwee the umber of projected umber of urses ad the curret umber of urses, usig the Cofe method,, idicatig that the umber of urses was lower tha the proportio recommeded by Cofe. I Hospital C, there was a sigificat differece i two uits betwee the projected umber urses ad the curret umber of urses, usig the Cofe method, idicatig the umber of urses exceeded the proportio recommeded by Cofe. The other uits had a adequate umber of ursig professioals. Nursig staff costs i Hospitals A, B ad C As show i Chart 1, the mea total mothly wage costs for curret ursig staff was R$755,408 i Hospital A, R$476,506 i Hospital B ad R$ 621,791 i Hospital C. It ca be see that the mea aual hourly cost of the urse category i Hospital A was 3.24 times that of Hospital C ad 1.75 times that of Hospital B. The mea aual hourly cost of the urse category i Hospital B was 1.85 times that of Hospital C. I relatio to the ursig techicia/aide category, the mea aual hourly cost i Hospital A was 3.83 times that of Hospital C ad 1.83 times that of Hospital B. The mea aual hourly cost of this category i Hospital B was 2.09 times that of Hospital C. Mothly workig hours (203.36 hours) were higher i Hospital C, followed by Hospitals A ad B. Mothly workig hours i Hospital C were 1.41 times that of Hospital A ad 1.7 times that of Hospital B. The workig hours of Hospital A were 1.2 times that of Hospital B. The mea hourly ad mothly cost for the miimum projected umber of ursig professioals accordig to Cofe Resolutio No. 293/04 (3) by professioal category ad daily workig hours are preseted i Chart 2, where it ca be oted that the mea mothly cost of the projected team would be R$896,734.08 i Hospital A, R$615,494.40 i Hospital B ad R$522,762.78 i Hospital C. I charts 1 ad 2, it ca be see that the qualitative ad quatitative adjustmet of ursig staff, accordig to the miimum parameters i Cofe Resolutio No. 293/04, would represet a mothly icrease of R$141,325.92 for Hospital A, by addig 13 urses ad elimiatig 5 ursig techicias/aides; a icrease of R$138,988.80 for Hospital B by addig 31 urses ad elimiatig 18 ursig techicias/aides; ad a R$99,028 reductio for Hospital C by elimiatig 8 urses ad 16 ursig techicias/aides. DISCUSSION I most of the uits studied, the ursig staff was quatitatively sufficiet, accordig to Cofe parameters. Oly oe uit i Hospital B had a lower umber of professioals tha the projected umber accordig to Cofe parameters. 50 Rev Esc Eferm USP 2015; 49(Esp2):47-53
Chart 1 - Distributio of the mea of curret umber ursig professioals ad the mea of aual hourly costs ad mothly wage costs, accordig to professioal category ad daily workig hours - São Paulo, 2014. Curret professioal category - Hospital A Mea aual hourly cost Mea total mothly wage cost (144 hours) Nurse 17 R$98.06 R$14,120.64 R$240,050.88 Nursig Techicia/Aide 61 R$58.67 R$8,448.48 R$15,357.28 curret team 78 - - R$755,408.16 Curret professioal category - Hospital B Mea aual hourly cost Mea total mothly wage cost (120 hours) Nurse 15 R$55.92 R$6,710.40 R$100,656.00 Nursig Techicia/Aide 98 R$31.96 R$3,835.20 R$375,849.60 curret team 113 - - R$ 476,505.60 Curret professioal category - Hospital C Mea aual hourly cost Mea total mothly wage cost (203.36 hours) Nurse 53 R$30.23 R$6,147.57 R$325,821.21 Nursig Techicia/Aide 95 R$15.32 R$3,115.47 R$295,969.65 curret team 148 - - R$621,790.86 Chart 2 - Distributio of the miimum projected umber of ursig professioals ad mea hourly ad mothly cost, accordig to professioal category ad daily workig hours - São Paulo, 2014. Projected professioal category - Hospital A Variace i umber of professioals Mea aual hourly cost Mea total mothly wage cost (144 hours) Wage variace Nurse 30 + 76.4% R$98.06 R$14,120.64 R$423,619.20 - Nursig Techicia/Aide 56-8.2 R$58.67 R$8,448.48 R$473,114.88 - Projected total team 86 + 68.2% - - R$896,734.08 +18.7% Projected professioal category - Hospital B Variace i umber of professioals Mea aual hourly cost Mea total mothly wage cost (120 hours) Wage variace Nurse 46 + 206.6% R$55.92 R$6,710.40 R$308,678.40 - Nursig Techicia/Aide 80 +/- 18.3% R$31.96 R$,835.20 R$306,816.00 - Projected total team 126 + 188.3% - - R$615,494.40 + 29.1% Projected professioal category - Hospital C Variace i umber of professioals Mea aual hourly cost Mea total mothly wage cost (203.36 hours) Wage variace Nurse 45 +/- 15.1% R$30.23 R$6,147.57 R$276,640.65 - Nursig Techicia/Aide 79 +/- 16.8% R$15.32 R$3,115.47 R$246,122.13 - Projected total team 124: +/- 31.9% - - R$522,762.78 +/- 15.9% I two uits of Hospital C, the umber of professioals exceeded the projected umber accordig to Cofe, which represets the miimum parameter for determiig the size of ursig teams. However, with respect to the percetage distributio of ursig professioals, it was oted that, except for the uits from Hospital C, the umber of urses i the uits of Hospitals A ad B were lower tha that recommeded by Cofe. The variace i the umber of urses idicated the eed for 76.4% more urses i Hospital A ad 206.6% more i Hospital B. I Hospital C, this variace correspoded to a reductio of 15.1% i urses. This fidig corroborates the results of aother study (6) that showed that the proportio of urses i most Brazilia health istitutios was lower tha the distributio recommeded by Cofe, which represets a stadard to be achieved by hospital istitutios i Brazil. Nursig staff adjustmets, maily i terms of adjustig the proportio of urses i relatio to ursig techicias/aides, represeted a 18.7% icrease i persoel costs i Hospital A ad 29.1% i Hospital B, ad a 15.9% reductio i Hospital C. The compositio of the ursig staff, cotractual workig hours, ad wages were variables examied i order to recocile costs ad huma resources i the iteral medicie ad surgical uits of Hospitals A, B ad C. However, other variables could have a ifluece o cost estimates, such as umber of beds, care complexity ad available techological resources. Kowledge of these variables, combied with costs, could assist i the decisio-makig process regardig adjustmets i curret staff i light of care eeds ad legal requiremets. From this perspective, urses eed to determie quatitatively ad qualitatively determie the umber of professioals eeded to achieve the desired stadards of care, ad aalyze the fiacial impact of these resources o the outcome of care activities carried out by ursig teams, cosiderig that although ecoomic aspects are importat, they should ot override techical, huma, ethical ad social aspects whe makig decisios (7). Rev Esc Eferm USP 2015; 49(Esp2):47-53 51
Nursig staff i the iteral medicie ad surgical uits of teachig hospitals: compositio ad cost A recet study (8) coducted i ie Europea coutries to provide iformatio about ursig professioals i hospitals foud that measures to curb spedig that focus quatitatively ad qualitatively o ursig professioals ca expose users to risk ad adversely affect patiet care outcomes, suggestig that a greater umber of urses providig care could reduce prevetable hospital deaths. Therefore, urses also eed to seek kowledge, skills ad competecies that support egotiatios i referece to the ursig staff, demostratig that while adjustig the umber of professioals may result i higher operatig costs, it ca help reduce expeses arisig from egative care outcomes that are due to quatitative ad/or qualitative isufficiecy i professioals (7). CONCLUSION The cotributio of this study is its proposed method for qualitatively ad quatitatively evaluatig ursig staffs, as well as determiig the mea cost for staff adjustmets. The results merit careful aalysis ad iterpretatio so that decisios ca be made that will promote efficiet supply ad distributio of ursig professioals, i quatitative ad qualitative terms, to meet desired quality ad safety stadards. The use of this method i other situatios ad correlatio of the results with care ad maagemet quality idicators could help to scietifically demostrate the impact of ursig staffs o patiet outcomes ad health istitutios. RESUMO Objetivo: Avaliar o quadro quati-qualitativo médio de profissioais de efermagem em serviço as uidades médico-cirúrgicas de três hospitais gerais, públicos e de esio, do muicípio de São Paulo frete ao quadro médio projetado, segudo parâmetros da Resolução Cofe º 293/04 e mesurar o custo médio dos quadros em serviço e projetado. Método: Estudo quatitativo, exploratório descritivo, com coleta prospectiva de dados. Resultados: Na maioria das uidades estudadas o quadro de profissioais de efermagem está quatitativamete adequado. Em duas Istituições a proporção de efermeiras é iferior ao precoizado pelo Cofe. O ajuste quali-quatitativo do quadro represetaria acréscimo mesal de R$ 141.325,92 para o Hospital A; R$ 138.988,80 para o Hospital B e redução de R$ 99.028,00 para o Hospital C. Coclusão: A pricipal cotribuição deste estudo reside a proposição de um método para avaliação quali-quatitativa do quadro de profissioais de efermagem, bem como para determiação do custo médio de sua adequação. DESCRITORES Efermagem; Recursos Humaos de Efermagem o Hospital; Carga de Trabalho; Custos e Aálise de Custo. RESUMEN Objetivo: Evaluar el promedio del cuadro cuatitativo y cualitativo de los profesioales de efermería que presta servicio e las uidades médico-quirúrgicas de tres hospitales geerales, públicos y de eseñaza, del muicipio de São Paulo, frete al cuadro medio proyectado segú los parámetros de la Resolució Cofe 293/04 y mesurar el promedio de costo de los cuadros e servicio y proyectado Método: estudio cuatitativo, descriptivo, exploratorio, co recolecció prospectiva de datos. Resultados: e la mayoría de las uidades estudiadas el cuadro de los profesioales de efermería está cuatitativamete adecuado. E dos istitucioes, la proporció de efermeras es iferior a la recomedada por el Cofe. El ajuste cualitativo y cuatitativo del cuadro represeta u icremeto mesual de R$ 141,325.92 para el Hospital A; R$ 138,988.80 al hospital B y la reducció de R$ 99,028.00 al hospital C. Coclusió: la pricipal cotribució de este estudio está e propoer u método de evaluació cualitativa y cuatitativa de los profesioales de efermería, así como para determiar el promedio de costo de su adecuació. DESCRIPTORES Efermería; Persoal de Efermería e Hospital; Carga de Trabajo; Costos y Aálisis de Costos. Refereces 1. Brasil. Miistério da Saúde; Secretaria de Gestão do Trabalho e da Educação a Saúde, Departameto de Gestão e da Regulação do Trabalho em Saúde. Gestão do trabalho e da regulação profissioal em saúde: ageda positiva. 3ª ed. Brasília: MS; 2009. 2. Garcia EA, Fuguli FMT. Nurses work time distributio at the emergecy service. Rev Esc Eferm USP [Iteret]. 2010 [cited 2014 Oct 24];44(4): 1032-8. Available from: http://www.scielo.br/pdf/reeusp/v444/e_25.pdf 3. Coselho Federal de Efermagem. Resolução 293/2004. Fixa e estabelece parâmetros para o Dimesioameto do Quadro de Profissioais de Efermagem as Uidades Assisteciais das Istituições de Saúde e Assemelhados [Iteret]. Brasília: COFEN; 2004 [cited 2014 Ja. 14]. Available from: http://www.cofe.gov.br/resoluo-cofe-2932004_4329.html 4. Fuguli FMT, Gaidziski RR, Kurcgat P. Sistema de classificação de pacietes: idetificação do perfil assistecial dos pacietes uidades de iteração do HU-USP. Rev Latio Am Efermagem [Iteret]. 2005[cited 2014 Oct. 24, 2015];13(1):72-8. Available from: http://www.scielo.br/pdf/rlae/v131/v131a12.pdf 5. Castilho V, Fuguli FMT, Gaidziski RR. Gereciameto de custos os serviços de efermagem. I: Kurcgat P, coordeadora. Gereciameto em efermagem. 2ª ed. Rio de Jaeiro: Guaabara Kooga; 2010. p. 121-35. 6. Fuguli FMT. Parâmetros oficiais para o dimesioameto de profissioais de efermagem em istituições hospitalares: aálise da resolução COFEN º 293/04 [tese livre-docêcia]. São Paulo: Escola de Efermagem, Uiversidade de São Paulo; 2010. 52 Rev Esc Eferm USP 2015; 49(Esp2):47-53
7. Fuguli FMT, Lima AFC, Castilho V, Bochembuzio L, Costa JA, Castro L. Cost of ursig staffig adequacy i a eoatal uit. Rev Esc Eferm USP [Iteret]. 2011 [cited 2014 Oct 23];45(.spe): 1582-8. Available from: http://www.scielo.br/pdf/reeusp/v45spe/e_ v45spea07.pdf 8. Aike LH, Sloae DM, Bruyeel L, Va de Heede K, Griffiths P, Busse R, et al. Nurse staffig ad educatio ad hospital mortality i ie Europea coutries: a retrospective observatioal study. Lacet. 2014;383(9931):1824-30. Rev Esc Eferm USP 2015; 49(Esp2):47-53 53