PATIENT OUTCOMES AND HOSPITAL NURSES’ WORKLOAD: A CROSS-
SECTIONAL OBSERVATIONAL STUDY IN SLOVENIAN HOSPITALS USING THE 
RN4CAST SURVEY
Brigita SKELA-SAVIČ 1*, Tit ALBREHT 2, Walter SERMEUS 3, Bojana LOBE 4, Mateja BAHUN 1, Simon DELLO 3
1 Angela Boškin Faculty of Health Care, Spodnji Plavž 3, 4270 Jesenice, Slovenia
2 National Institut of Public Health Slovenia, Trubarjeva 2, 1000 Ljubljana, Slovenia
3 Leuven Institute for Healthcare Policy, University of Leuven, Kapucijnenvoer 35 blok d - bus 7001, 3000 Leuven, Belgium
4 Faculty of Social Sciences, University of Ljubljana, Topniška ulica 31, 1000 Ljubljana, Slovenia
Received: Sep 14, 2022
Accepted: Nov 24, 2022
Original scientific article
*Corresponding author: Tel. +386 4 5869 360; E-mail: bskelasavic@fzab.si
10.2478/sjph-2023-0009 Zdr Varst. 2023;62(2):59-66
59
IZIDI ZDRAVLJENJA PACIENTOV IN DELOVNA OBREMENITEV 
MEDICINSKIH SESTER V BOLNIŠNICAH: PRESEČNA OPAZOVALNA 
RAZISKAVA RN4CAST V SLOVENSKIH BOLNIŠNICAH
© National Institute of Public Health, Slovenia. 
Skela-Savič B, Albreht T, Sermeus W, Lobe B, Bahun M, Dello S. Patient outcomes and hospital nurses’ workload: A cross-sectional observational study in Slovenian hospitals using the 
RN4CAST survey. Zdr Varst. 2023;62(2):59-66. doi: 10.2478/Sjph-2023-0009.
ABSTRACT
Keywords: 
Work conditions
Staffing
RN
Patient deaths
Mortality
Practice environment
Bachelor of science
Unfinished tasks
Quality
Management  
IZVLEČEK
Ključne besede: 
delovne razmere
zaposlovanje
medicinske sestre
smrti bolnikov
umrljivost
delovno okolje
dodiplomski študij
nedokončane naloge
kakovost
menedžment
Introduction: Higher nursing workload increases the odds of patient deaths, as the work environment has 
a significant effect on patient outcomes. The aim of the study was to explore the relation between patient 
outcomes and nurses’ working conditions in hospitals.
Methods: Administrative data on discharges of surgical patients for the year 2019 in eight general hospitals and 
two university medical centres in Slovenia were collected to determine in-hospital mortality within 30 days of 
admission. The RN4CAST survey questionnaire was used to gather data from nurses in these hospitals, with 
1,010 nurses participating. Data was collected at the beginning of 2020. The number of nurses per shift and 
the nurse-to-patient ratio per shift were calculated. Univariate, bivariate and multivariate statistical methods 
were used to analyse the data.  
Results: The 30-day in-hospital mortality for surgical patients was 1.00% in the hospitals sampled and ranged 
from 0.27% to 1.62%. The odds ratio for staffing suggests that each increase of one patient per RN is associated 
with a 6% increase in the likelihood of a patient dying within 30 days of admission. The mean patient-to-RN 
ratio was 15.56 (SD=2.50) and varied from 10.29 to 19.39. Four of the 13 tasks checked were not performed on 
patients during the last shift.
Conclusion: The results are not encouraging, with an extremely critical shortage of RNs and thus a high RN 
workload. The number of patients per RN is the highest in Europe and also higher than in some non-European 
countries, and represents an extreme risk to the quality of nursing and healthcare as a whole. The recommendation 
for acute non-emergency internal medicine and surgery departments is four patients per RN per shift.
Uvod: Večje delovne obremenitve medicinskih sester povečujejo verjetnost smrti pacientov. Delovno okolje 
medicinskih sester pomembno vpliva na izide zdravljenja. Namen raziskave je bil pojasniti povezavo med izidi 
zdravljenja pacientov in delovnimi razmerami medicinskih sester v bolnišnicah.
Metode: Zbrani so bili administrativni podatki o odpustu kirurških pacientov iz leta 2019 v osmih splošnih 
bolnišnicah in dveh univerzitetnih kliničnih centrih v Sloveniji, da bi ugotovili bolnišnično umrljivost v 30 
dneh po sprejemu. Za zajem podatkov pri medicinskih sestrah v istih bolnišnicah je bil uporabljen vprašalnik 
raziskave RN4CAST. Sodelovalo je 1.010 medicinskih sester. Ti podatki so bili zbrani v začetku leta 2020. 
Izračunana sta bila število zaposlenih medicinskih sester v delovni izmeni ter razmerje med številom pacientov 
in številom medicinskih sester v delovni izmeni. Za analizo podatkov so bile uporabljene univariatne, bivariatne 
in multivariatne statistične metode.  
Rezultati: Tridesetdnevna bolnišnična umrljivost kirurških pacientov je bila v vzorčenih bolnišnicah 
1,00-odstotna in je znašala od 0,27 do 1,62 %. Razmerje možnosti za osebje kaže, da je vsako povečanje 
za enega pacienta na diplomirano medicinsko sestro povezano s 6-odstotnim povečanjem verjetnosti, da bo 
pacient umrl v 30 dneh po sprejemu. Povprečno razmerje pacientov na eno diplomirano medicinsko sestro je 
bilo 15,56 (SD = 2,50) in se je gibalo med 10,29 in 19,39. Štiri od trinajstih preverjenih nalog pri pacientu v zadnji 
izmeni niso bile opravljene.
Zaključek: Rezultati niso spodbudni, saj je pomanjkanje diplomiranih medicinskih sester izjemno kritično. 
Izpostavljena je njihova velika obremenitev. Število pacientov na eno diplomirano medicinsko sestro je najvišje v 
evropskih državah in širše ter predstavlja izjemno tveganje za kakovost zdravstvene nege in zdravstvene oskrbe 
kot celote v Sloveniji. Priporočilo za akutne internistične in kirurške oddelke, brez obravnav na intenzivni negi, 
je štiri paciente na eno diplomirano medicinsko sestro v delovni izmeni. 
1 INTRODUCTION
The Nurse Forecasting (RN4CAST) study in Europe aims 
to simulate scenarios to illustrate what happens to the 
quality of patient care and nursing outcomes when 
different aspects of the nursing (RNs) workforce (nurse-
to-patient ratio, nurse education, nurse skill mix, 
nursing work environment) are changed. Unfortunately, 
Slovenia was not included in the launch of the European 
Commission study in twelve European countries in the 
period 2010-2011. 
1.1 Background  
Research has consistently shown that higher nursing 
workloads increase the odds of patient deaths. In hospital 
settings where RNs provide care to a greater number 
of patients per shift, where their work environment 
is unsupportive and managers do not respond to RNs’ 
concerns, patients have poor health outcomes and RNs 
report greater burnout, job dissatisfaction, and intent 
to leave (1 - 4). When nurses care for fewer patients 
at a time, they are able to spend more time at each 
patient’s bedside, and as a result patients are less likely 
to experience an adverse outcome, the length of stay is 
shorter, and there are cost savings for the hospital (5). 
Griffiths (6) states that staff shortages can lead to a 
proportion of nurses abandoning the provision of services, 
which is a direct indicator of inadequate staffing levels in 
nursing, as has been shown in international studies (7).
Longitudinal findings revealed an association between 
increased proportions of bachelor of science RNs (BSN) and 
improvements in patient outcomes; higher proportions of 
BSNs were associated with lower odds of 30-day inpatient 
surgical mortality (1, 6, 8). The BSN educational pathway 
(four-year study programme) is recommended for at 
least 80% of the BSN workforce (8 - 11). Higher hospital 
proportions of BSN nurses, regardless of educational 
pathway, are associated with lower odds of 30-day 
inpatient surgical mortality (5, 9). 
Schlak et al. (3) found that the work environment had 
a significant effect on patient outcomes, as a change 
in the work environment from poor to mixed or mixed 
to good was associated with a 14% drop in the odds of 
30-day in-hospital mortality. Addressing staffing without 
improving the practice environment would be ineffective 
(12), because better staffing and practice environments 
are associated with improved patient outcomes (1, 3, 8, 13 
- 15). The cumulative evidence suggests that interventions 
to improve hospital work environments and patient-to-
nurse staffing ratios may be key to addressing quality, 
safety, and nurse workforce concerns (4), and staffing 
is a key variable for patient mortality within 30 days of 
admission, readmission, and hospitalisation time (15).
10.2478/sjph-2023-0009 Zdr Varst. 2023;62(2):59-66
60
1.2 Situation in Slovenia
Slovenia faces a major shortage of RNs, with only 30% 
of RNs in the nursing workforce group, a far cry from 
recommendations noted above – 80% of nurses with a 
bachelor of science in nursing (BSN) (9, 11). The title of 
nurse (RN) describes anyone meeting the European Union 
(EU) definition of a trained and licensed nurse according 
to Directive 2013/55/EU (16). In Slovenia, this corresponds 
to having an undergraduate three-year professional 
bachelor’s degree in nursing, level six of the European 
Qualifications Framework (EQF). The education level of 
healthcare assistants (HCAs) is four years of secondary 
school for healthcare technicians, level four of the EQF. 
For years, health policymakers on Slovenia have been 
neglecting the need to increase the number of nurses 
with a minimum of a professional bachelor’s degree in 
clinical settings and educate them to a four-year bachelor 
of science in nursing (BSN). Most European Union countries 
have switched from a three-year professional nursing 
degree to a four-year science degree because students’ 
workloads were too high and the three-year professional 
degree is too short to deliver the competences set out in 
the 2013 update of the Directive (16). 
1.3 The aims
The first aim of our study is to explore the relation 
between patient outcomes and nurses’ working conditions 
in hospitals. The second is to describe nurses’ workloads 
and place them in an international context. 
2 METHODS
2.1 Design and setting 
For this observational study with a cross-sectional design, 
administrative discharge data on surgical patients for 
the year 2019 was collected in all acute care hospitals 
in Slovenia. Nurses in all general hospitals (n=10) and 
university clinical centres (n=2) were invited to participate 
in a survey to estimate nurse staffing. Eight general 
hospitals and two university clinical centres participated 
in the survey (n=10). Nurses in participating hospitals 
providing direct patient care on surgical and medical 
inpatient units (n=2813) were invited to participate in the 
survey between February and March 2020. 
2.2 Sample of nurses
The overall response rate for the nurse survey was 35.90% 
and varied across hospitals, ranging from 21.97% to 85.71%. 
Respondents included 848 (83.96%) women and 160 
(15.84%) men, while the average age was 37.02 (SD=10.65) 
years. The average length of employment in nursing was 
15.34 years (SD=11.12). Almost all the respondents (96.2%) 
were employed full time. On average, 35.65% (n=403) of 
nursing care providers had completed an undergraduate 
10.2478/sjph-2023-0009 Zdr Varst. 2023;62(2):59-66
61
professional bachelor’s programme, which varied from 
23.68% to 48.76%, depending on the hospital (Table 2); on 
average 59.9% (605) were HCAs.
2.3 Instruments for nurses
The RN4CAST survey instrument comprises a core battery 
of extensively validated instruments and questions (17). In 
this article, we will present data on nurse staffing levels 
and education, and a description of recent changes in 
hospitals (duration of shift, aspects of responsibility for 
patients, roles in nursing care, number of RNs and HCAs 
on the ward, performance of various tasks, and tasks 
they should have completed and did not). The possible 
answers to each question are described in the results. The 
last part of the instrument includes demographic data. 
Using the same approach as in RN4CAST (18), forward 
and backward translations of the survey instrument were 
conducted independently by two qualified translators. 
2.4 Patient outcome variables
Patient data was provided by the National Institute of 
Public Health in Slovenia to analyse the links between 
patient outcomes and nurses’ working conditions. The 
primary outcome of interest is in-hospital mortality within 
30 days of admission. Primary and secondary diagnoses 
were coded using the tenth version of the International 
Classification of Diseases (19). When modelling mortality, 
only patients with a primary diagnosis in ICD-10 blocks S 
(Injury), M (Disease of musculoskeletal system), K (Disease 
of digestive system), I (Disease of circulatory system), 
and C (Malignant neoplasm) were included. The analysis 
included surgical patients aged 18 years or older with a 
hospital stay of at least two days or more, and for whom 
complete data was available for comorbidities, discharge 
status, and other variables used for risk adjustment. 
Risk adjustment variables at the individual patient level 
include patient age, gender, admission type (emergency 
or elective), and the Charlson Comorbidity index (20, 21). 
2.5 Ethical approval 
Permission to conduct the study was obtained from the 
National Medical Ethics Committee (No. 0120-488/2019/6, 
January 7, 2020), and all actions were carried out in 
accordance with relevant guidelines and regulations (22). 
The participants gave their written informed consent 
to participate in the study and permission to use the 
data collected at the national level for professional and 
scientific purposes. The informed consent to publish in 
scientific journals (online, open-access) was also obtained 
from the study participants.  
2.6 Statistical analysis
Nurse staffing was calculated by averaging the patient-to-
nurse ratios – as reported by each nurse – for the hospital 
level. The patient-to-nurse ratio at the individual nurse 
level was calculated by dividing the number patients by 
the number of nurses with an undergraduate professional 
bachelor’s degree present on the ward on their most 
recent shift. A low ratio reflects a more favourable staffing 
situation. The association between nurse staffing, nurse 
education and 30-day in-hospital mortality is estimated 
before and after adjusting for hospital characteristics and 
risk-adjustment for individual patient characteristics. Using 
a generalised linear model, individual patient outcomes 
were modelled using a combination of both hospital and 
patient characteristics. This approach allowed us to take 
the hierarchical structure of the data (i.e. patients nested 
within hospitals) into account. Descriptive and bivariate 
statistics were used to analyse the data obtained from 
the nurses using the instrument. Analyses were conducted 
using SAS version 9.4 for Windows and SPSS version 20.0.
3 RESULTS
3.1 Patient outcomes 
The mean age of patients sampled was 59.62 years 
(SD=17.25), all other patient characteristics are provided in 
Table 1. Of the 36,037 patients included, 18,768 were men 
(52.08 %) and 17,269 (47.92 %) were women, and 29.64% had 
a primary diagnosis in ICD10-block M, while only 6.53% had 
a primary diagnosis in ICD10-block C. The most common 
comorbidities were diabetes without complication, 
congestive heart failure, and malignancy (Table 1). 
Men
Emergency admissions
Inpatient deaths within 30 days of admission
Categories
Injury – S
Disease of musculoskeletal system – M
Disease of digestive system – K
Disease of circulatory system – I
Malignant neoplasm – C
Comorbidities
Myocardial infarction
Congestive heart failure
Peripheral vascular disease
Cerebrovascular disease
Dementia
Chronic pulmonary disease
Rheumatic disease
Peptic ulcer disease
Mild liver disease
Diabetes without chronic complication
Diabetes with chronic complication
Hemiplegia or paraplegia
Renal disease
Malignancy
Moderate or severe liver disease
Metastatic solid tumour
AIDS/HIV
18,768 (52.08)
10,682 (29.64)
359 (1.00)
9,842 (27.31)
10,680 (29.64)
10,322 (28.64)
2,841 (7.88)
2,352 (6.53)
437 (1.21)
978 (2.71)
517 (1.43)
483 (1.34)
387 (1.07)
667 (1.85)
151 (0.42)
50 (0.14)
230 (0.64)
1 866 (5.18)
199 (0.55)
82 (0.23)
473 (1.31)
677 (1.88)
44 (0.12)
591 (1.64)
0 (0)
Number
Table 1. Patient characteristics (n=36,037) in the included hospitals.
10.2478/sjph-2023-0009 Zdr Varst. 2023;62(2):59-66
62
Mortality data was obtained for 36,037 patients; the 
number of discharges varied across hospitals (Table 2). The 
30-day in-hospital mortality for surgical patients was 1.00% 
in the hospitals sampled and ranged from 0.27% to 1.62%.
AC
AH
BK
BU
DQ
EA
EF
FH
FZ
HG
Total
Model – all together
26 / 2,440 (1.05)
9 / 1,082 (0.82)
28 / 3,079 (0.90)
40 / 4,076 (0.97)
13 / 1,817 (0.71)
107 / 10,680 (0.99)
12 / 2,672 (0.45)
5 / 1,844 (0.27)
102 / 6,193 (1.62)
17 / 1,795 (0.94)
359 / 3,6037 (1.00)
Staffing
Education
42.22
32.25
29.26
48.76
33.33
46.18
29.16
28.94
42.64
23.68
35.65
1.008 (0.932-1.090)
1.024 (1.002-1.046)
1.059 (1.011-1.110)
1.011 (0.984-1.039)
0.838
0.032
0.016
0.436
15.7179
17.1000
17.5083
14.0615
15.6152
10.2855
14.3178
19.3851
17.1487
14.4306
15.56
Deaths / Discharges (%) RNs (%)
Unadjusted model
OR 95% CI
   Adjusted model
OR 95% CI
p-value p-value
Patient-to-RN ratio (M)Hospital
Table 2.
Table 3.
Number of deaths and discharges per hospital, overall (%) of RNs and patient-to-RN ratio.
Adjusted and unadjusted odds ratios showing the effects of nurse staffing and nurse education on 30 day in-hospital mortality.
Table 3 shows the effect of nurse staffing and nurse 
education on 30 day in-hospital mortality, both unadjusted 
and adjusted for potential confounders. In the unadjusted 
model, only nurse education is significantly associated 
with mortality. After considering the severity of patients’ 
illness, patient characteristics, and hospital characteristics 
(bedside), only nurse staffing was significantly associated 
with mortality in the adjusted model (Table 3). The odds 
ratio for staffing suggests that each increase of one patient 
per RN is associated with a 6% increase in the likelihood of 
a patient dying within 30-days of admission.
3.2 Nurses’ workloads on recent shift 
The mean number of patients per inpatient ward 
during the last work shift of the respondents was 25.17 
(SD=14,390). The mean patient-to-RN ratio was 15.56 
(SD=2.50) and varied from 10.29 to 19.39 (Table 2). One 
HCA was responsible for an average of 8.62 (SD=5.675) 
patients. The difference between RNs and HCAs is 
significant, with the latter significantly less burdened than 
the former (p<0.001). 
The mean number of RNs per ward during the most recent 
work shift was 2.06 (SD=1.412), compared to 3.60 HCAs 
(SD=2.800) (p<0.001). 
The self-assessed number of patients for whom respondents 
were directly responsible during the last shift was 17.42 
(SD=11.84); RNs’ assessment was significantly higher at 
19.09 (SD=14.42) compared to HCAs’ assessment at 16.38 
(SD=9.64) (p<0.001). A total of 55.4% respondents reported 
their direct responsibility for patients did not differ from 
the usual level, while 31.1% felt they were less burdened 
than usual. 
The mean duration of the most recent shift was 9.42 hours 
(SD=5.518), with no significant differences between RNs 
and HCAs. 
An average of 8.85 (SD=7.555) patients for whom the 
respondents were responsible during the last shift 
needed assistance with all activities of daily living and 
5.40 (SD=5.923) needed monitoring for an hour or less 
or healthcare interventions. RNs were significantly more 
burdened in patients’ daily living activities (M=9.55, 
SD=8,83, p=0.023) compared to HCAs (M=8.41, SD=6.57), 
with no differences in monitoring the patients between 
the two nursing groups (p=919). 
A total of 54.9% (n=523) respondents estimated they 
provided most care to the patients themselves, 31.3% 
(n=298) supervised other providers in addition to providing 
direct nursing care, 11.1% (n=106) responded that they 
were involved in the direct work (dressing wounds, 
administering medication) in a minor way, with most of 
the direct nursing care being provided by others. The 
difference is significant in the category of supervision of 
10.2478/sjph-2023-0009 Zdr Varst. 2023;62(2):59-66
63
Delivering and retrieving food trays 
Performing non-nursing care 
Arranging discharge referrals and 
transportation (including to long-term care)
Routine phlebotomy/blood draw for tests
Transporting of patients within hospital
Cleaning patient rooms and equipment
Filling in for non-nursing services 
not available on off-hours
Obtaining supplies or equipment 
Answering phones, clerical duties
Comfort and talk with patients
Educating patients and family
Adequate patient surveillance
Developing or updating nursing care plans or care pathways
Frequent changing of patient position
Oral hygiene
Adequately document nursing care 
Planning care
Skin care
Prepare patients and families for discharge
Administer medications on time
Treatments and procedures
Pain management
Composite score
993
987
992 
983
986
991
976 
989
998
1000
1001
1001
1000
1001
1001
1001
1001
1001
1001
1001
1001
1001
588/1,009 (58.3) [41.9 – 72.7]
563/1,008 (55.9) [32.3 – 61.9]
362/1,010 (35.8) [22.6 – 47.4]
362/1,010 (35.8) [22.6 – 53.3]
322/1,010 (31.9) [19.7 – 49.1]
317/1,009 (31.4) [21.1 – 54.4]
294/1,010 (29.1) [15.8 – 42.9]
272/1,010 (26.9) [9.7 – 50.0]
275/1,010 (23.2) [7.9 – 40.9]
221/1,010 (21.9) [6.45 – 28.6]
175/1,009 (17.3) [3.2 – 28.6]
138/1,010 (13.7) [6.6 – 21.4]
105/1,010 (10.4) [2.6 – 19.1]
Mean=3.9 (SD=0.7)
Min=2.7 – Max=5.1
0.060
0.067
0.006
<0.001
0.043
0.501
0.006
<0.001
0.614
0.015
0.937
0.174
0.088
17.1
6.1
32.9 
48.9
22.9
16.3
25.5 
12.8
2.0
58.2
44.4
36.8 
37.5
39.8
47.2
25.4 
46.3
82.6
32.9
40.5
51 
76.1
32.6
28.3
20.3 
49.6
89
76.7
46.8
27.4 
11.1
44.7
59.9
29 
44.1
78.4
<0.001
0.114
<0.001 
<0.001
<0.001
<0.001
<0.001 
0.308
<0.001
23.1
49.4
30.3 
13.4
37.1
36.3
49.1 
40.8
15.2
n
n % (min – max) Impact of education
(p bold - lower presence 
in group RNs)
Never
%
Often
%
RN Often
%
HCA Often
%
Education
p
Sometimes
%
Items
Item
Table 4.
Table 5.
Frequency of different tasks during the most recent work shift and differences in educational level.
Tasks respondents should have performed during their last shift but did not due to lack of time.
the nursing care provided, as RNs (46.6%, n=179) (p<0.001) 
act as both providers and as those responsible for the 
nursing care provided in the nursing team, in contrast to 
HCAs (21%, n=119).
Table 4 shows the frequency of the different tasks during 
the last work shift. RNs are typically more likely to answer 
the telephone, perform routine blood draws, handle patient 
discharge tasks, and obtain supplies or equipment. HCAs 
typically answer the telephone, take care of food service, 
clean patient rooms and equipment, perform non-nursing 
care, transport non-threatened patients, obtain supplies or 
equipment, and perform other services (Table 4).
The respondents were asked which tasks they should 
have performed during their last shift but did not due to 
lack of time (Table 5). The tasks that stood out the most 
were ensuring comfort and engaging in conversation 
with patients, educating patients and family, appropriate 
supervision of patients, care planning, etc. On average, four 
of the planned tasks were not performed during the most 
recent shift. More detailed results are shown in Table 5. 
4 DISCUSSION 
The results reported in this study are not encouraging for 
patient outcomes in Slovenia, nor for other countries in 
Europe and elsewhere where there is an extremely critical 
shortage of RNs, and thus a high RN workload. In Slovenia, 
the number of patients per RN is the highest in Europe (24) 
and also higher than in some non-European countries (15), 
and represents an extreme risk to the quality of nursing 
and healthcare as a whole, as is evident from our study. 
The recommendation for acute non-emergency internal 
medicine and surgery departments is four patients per RN 
per shift (23), but in our study this workload was found 
10.2478/sjph-2023-0009 Zdr Varst. 2023;62(2):59-66
64
to be 15.6 patients per RN on average. An additional 
increase in the number of patients per RN translates into 
an average 6% increase in the risk of death within 30 days 
of admission for each added patient in the participating 
hospitals. Many studies have shown that increasing nurses’ 
workload increases the likelihood of a patient dying within 
30 days of admission, as summarised by Aiken et al. (21) in 
a recent article. They found that those patients admitted 
to hospitals with 18 patients per nurse had a 41% higher 
probability of dying, compared to those admitted to 
hospitals with eight patients per nurse. The differences 
in patient mortality between the hospitals in our study 
are substantial and are related to differences in the level 
of nurse employment. The findings related to the effect 
of nurse staffing in the Slovenian study reported here are 
comparable to the findings of the seminal work by Linda 
Aiken et al. (1, 8, 13, 15, 24).
In our study, only just over a third of nursing staff have 
a higher educational qualification that is in line with the 
minimum European guidelines for nursing education (16). 
The number of RNs is not in line with the international 
recommendations (11, 23) followed by most European 
countries (25), i.e. the transformation of three-year 
higher professional education programmes into four-year 
university degree programmes. Healthcare personnel 
educated at secondary school level (HCAs) account for as 
much as two-thirds of the total workforce, which is one of 
the worst ratios in Europe (13, 24, 25) and elsewhere (9, 
15). With regard to RNs, many countries have found that 
better outcomes were obtained when RNs were educated 
to BSN level or above (1, 15, 24, 25). We did not find this 
to be the case in our study, as there was no difference 
within the group of Slovenian RNs as the vast majority 
have a three-year undergraduate professional degree, and 
the number of those with a higher degree (professional 
master’s level) in the RN population is too small to have an 
effect on patient outcomes in our study, whereas most of 
the countries included in the RN4CAST study did see this 
impact (1, 8, 9, 15, 24). This is because these countries 
have changed their educational systems, and the groups 
educated under the reformed programmes are sufficiently 
large. In Slovenia, there have been no changes to the 
length of study since 1996. A meta-analysis showed that 
patients who receive care from a nurse with a BSN degree 
or higher had a 5% lower odds of 30-day mortality. BSN 
preparation or higher was also associated with decreasing 
failure-to-rescue by 6%, and was also significant in the 
meta-analysis (26).
An important finding of the current study is that the ratio 
of RNs to HCAs varies by hospital, which suggests that the 
observed proportion of RNs is also related to the staffing 
policy of each hospital, with the lowest proportion of RNs 
being 23.7% and the highest 48.9%. The workload of one RN 
during a shift thus varies between 10.3 and 19.4 patients, 
while HCAs are significantly less burdened, as there are 
always more HCAs than RNs on a shift. Aiken et al. (13) 
concluded that substituting one nurse assistant (HCA) for a 
professional nurse (RN) for every 25 patients is associated 
with a 21% increase in the odds of dying, and each 10% 
reduction in the proportion of professional nurses is 
associated with an 11% increase in the odds of death.
According to the RNs’ self-assessment, they provided 
direct nursing care to more than half of the patients 
assigned on their most recent shift. A third rated their last 
shift as less stressful compared to their average workload. 
For both occupational groups, the average working hours 
are an hour and a half longer than the norm. The workload 
resulting from direct patient work is also high, with more 
than half the patients needing assistance with all activities 
of daily living, and over a third needing monitoring or other 
healthcare interventions every hour. More than half of the 
respondents performed all patient activities themselves, 
while one third performed patient activities and were 
responsible for supervising other providers – these were 
typically RNs who are responsible for the nursing care 
provided in a nursing team. Content analysis of the work 
and its frequency showed that the focus is on professional 
tasks that fall within the RNs’ remit, hence the heavy 
workload. It is also evident that both RNs and HCAs are 
doing jobs and tasks that could be done by less skilled 
support staff or staff covering administrative tasks and 
less professional operational tasks of the hospital ward, 
such as delivering food and materials, answering the 
telephone, clerical work, cleaning the bed unit, and other 
non-nursing jobs. The proportion of tasks that should have 
been done for the patient but were not is high, and is the 
highest in the group of European countries that have used 
the RN4CAST survey (7). Top of the tasks left undone is 
engaging in conversation with and educating patients and 
their relatives, and this service is not accessible to more 
than half of patients. Also omitted for one third of patients 
is the prescribed patient monitoring, updating patient 
work plans, changing the patient’s position, and oral 
hygiene. The fewest undone tasks are in the area of pain 
therapy and the completion of diagnostic and therapeutic 
programmes. The hierarchy of abandonment reported here 
is comparable to that found in other European research (7, 
27). Chaboyer (27) found similar patterns of nursing care 
left undone across a cross-section of European hospitals, 
suggesting that nurses develop informal task hierarchies to 
facilitate important patient-care decisions. The composite 
score in that study was 3.6 (SD=1.2), in ours it was also 3.6 
(SD=0.7). Given this result, the inadequacy of staffing in 
the participating hospitals can be confirmed by the nursing 
care left undone in the other research. Researchers state 
that this figure is the most direct indicator of the adequacy 
of nursing staffing levels (6).
In existing research, the need to improve working 
conditions has been shown to be an important factor in the 
retention of nurses, as improving the work environment 
remains a solution for hospitals looking to reduce nurse 
burnout and improve patient outcomes (3). 
4.1 Guidelines for health management and health policy
The findings call for the unification of staffing norms in 
Slovenian hospitals and the consideration of the fact 
that the staffing policies of developed countries aim 
for an 80% share of BSN-educated nurses in the nursing 
workforce (11). Our findings support promoting multiple 
BSN educational pathways to reach the Institute of 
Medicine recommendation (8, 9). It has been shown that 
reducing the nursing skill mix by adding nursing associates 
and other categories of assistive nursing personnel 
without professional nursing qualifications may contribute 
to preventable deaths, erode the quality and safety of 
hospital care, and contribute to shortages of hospital 
nurses (13).
It is important to adopt staffing norms that will increase 
the number of BSN staff by 50% over the next decade. 
There is also an urgent need to reorganise the work 
and tasks at the level of the hospital ward and hospital 
so that non-nursing work and tasks, particularly those 
performed by RNs, are delegated to non-healthcare staff 
involved in helping the hospital ward run and performing 
administrative tasks. 
There is also a need to reform the nursing curricula and 
expand the nursing curriculum by one year to reach 
the BSN level. Employers should take the approach of 
sending HCAs to obtain higher nursing education in order 
to improve the ratio of HCAs to RNs as soon as possible, 
thereby also improving the input of nursing skills and the 
patient-to-RN ratio.
The results of this study have important implications for 
the management of Slovenian hospitals and for health 
policy. The long-known fact that Slovenia has the lowest 
proportion of adequately educated RNs according to the 
European Directive has been confirmed by our study. The 
consequences of the policy of overloading existing RNs are 
also related to patient mortality within 30 days of hospital 
admission in our study, which should be a clear message 
to health policymakers and healthcare managers that the 
long-standing limitation on the recruitment of RNs has 
negative consequences. Slovenia is the worst performing 
country for RNs in the EU. RNs are the most overworked 
and are also forced to omit the care that patients should 
receive – and here, too, the result is the worst in the 
EU. Economic analyses have shown that work-related 
complications have negative effects beyond making it 
difficult to recruit an adequate number of nurses and 
enabling them to develop their careers. Griffiths et al. 
(28) clearly show that staffing plans with higher baseline 
staff levels are highly cost effective. It is therefore high 
time to regard the recruitment, training and performance 
of nurses as an investment and not as a cost. Mandatory 
training in working with staff should be introduced for the 
appointment of health managers at macro and meso levels. 
Only educated managers and leaders can properly address 
the problems of providing an appropriate and supportive 
working environment in nursing, an issue which has been 
described by other authors in our cultural context (29-31). 
5 CONCLUSION 
The results reported here are not encouraging, with an 
extremely critical shortage of RNs and thus a high RN 
workload, as the number of patients per RN is the highest 
of all the European countries and many beyond the 
continent, representing an extreme risk to the quality of 
nursing and healthcare as a whole. The recommendation 
for acute non-emergency internal medicine and surgery 
departments is four patients per RN per shift. In 
retrospect, we have arrived at this situation in Slovenian 
hospitals by looking at the health system only from the 
perspective of physicians, but no health system can be 
effective unless all the health workers and allied health 
professionals involved are considered.  
ACKNOWLEDGMENT
The paper presents, in part, the results of a broader non-
profit applicative project entitled “Hospitals and faculties 
together for prosperous and scientific based healthcare 
(ProCare)”.
CONFLICTS OF INTEREST 
The authors report no conflicts of interest. The manuscript 
has not been published and is not under consideration for 
publication elsewhere. 
FUNDING 
The research was financed by the ERASMUS +, Action KA2 
(Project No. 601092-EPP-1-2018-1-SI-EPPKA2-KA) in the 
period 2018-2021. 
ETHICAL APPROVAL 
Received from the National Medical Ethics Committee of 
the Republic of Slovenia. 
10.2478/sjph-2023-0009 Zdr Varst. 2023;62(2):59-66
65
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