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.