Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care

Abstract

ObjectivesTo determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care.DesignCross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models.SettingAdult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland.ParticipantsSurvey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275 519 surgical patients in 188 of these hospitals.Main outcome measuresPatient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction.ResultsRicher nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death. In our hospital sample, there were an average of six caregivers for every 25 patients, four of whom were professional nurses. Substituting one nurse assistant for a professional nurse for every 25 patients is associated with a 21% increase in the odds of dying.ConclusionsA bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding nursing associates and other categories of assistive nursing personnel without professional nurse qualifications may contribute to preventable deaths, erode quality and safety of hospital care and contribute to hospital nurse shortages.

Association between workload of the nursing staff and patient safety outcomes

“…These results are consistent with the findings of other studies (1,8,(18)(19)22) , which indicate that better nurse staffing and the consequent increase in nursing hours for the patient have significant association (p<0.01) with lower rates of pressure ulcers, pneumonia, falls and sepsis, as well as with a reduction in medication errors and mortality. Thus, it is understood that the increase in the number of patients assigned to nurses is associated with negative quality and safety outcomes for hospitalized patients.…”

“…In European countries, the data found showed a variation of registered nurses in inpatient units ranging from 54% in Spain to 82% in Germany (26) . Recent research in European countries concluded that bedside care workforce with a higher proportion of professional nurses was associated with better patient outcomes and better working and safety conditions at the hospitals (22) . However, despite the growing evidence on the causal relationship between nurse staffing and better outcomes for the patients, the findings are still inconsistent when regarding the financial aspects involved in the adoption of policies for adequate nurse staffing in practice scenarios, both in international and Brazilian contexts.…”

Shrinking the state: The fate of the NHS and social care

“…At the same time, nursing researchers continue to reiterate that increased staffing by qualified nurses reduces patient mortality and morbidity. 6 Both in the US and in NHS STPs, there is strong advocacy of hospital mergers. Evidence of the cost effectiveness of this policy is sparse with US studies showing less concentrated markets have better quality care and lower prices.…”

Classificação de pacientes e dimensionamento de profissionais de enfermagem: contribuições de uma tecnologia de gestão

“…International studies, such as the one carried out in 243 hospitals in 6 European countries (4) and another carried out in 60 hospitals in South Korea (5) , show that there is a direct correlation between adequate care staff in quantity and quality with the assistance results involving directly the patient's safety and the quality of the services offered.…”