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

Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care
Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care
Objectives To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care.Design Cross-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.Setting Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland.Participants Survey 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 measures Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction.Results Richer 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.Conclusions A 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.
2044-5415
559-568
Aiken, Linda H.
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Sloane, Douglas
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Griffiths, Peter
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Rafferty, Anne Marie
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Bruyneel, Luk
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McHugh, Matthew
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Maier, Claudia B.
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Moreno-Casbas, Teresa
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Ball, Jane E.
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Ausserhofer, Dietmar
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Sermeus, Walter
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Aiken, Linda H.
6110096b-bab9-41a7-89f4-d7043011d6d9
Sloane, Douglas
10494ba7-bfc5-48db-996e-6773a265864a
Griffiths, Peter
ac7afec1-7d72-4b83-b016-3a43e245265b
Rafferty, Anne Marie
d82c2661-2b39-447c-b975-c42834480975
Bruyneel, Luk
b1dccbf8-34ee-4b11-b698-790131e1abb0
McHugh, Matthew
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Maier, Claudia B.
c4ddcab8-3cae-42a5-9163-547d17c76c36
Moreno-Casbas, Teresa
b0c80237-c1c2-4cfc-bb99-f9440407fdee
Ball, Jane E.
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Ausserhofer, Dietmar
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Sermeus, Walter
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Aiken, Linda H., Sloane, Douglas, Griffiths, Peter, Rafferty, Anne Marie, Bruyneel, Luk, McHugh, Matthew, Maier, Claudia B., Moreno-Casbas, Teresa, Ball, Jane E., Ausserhofer, Dietmar and Sermeus, Walter (2017) Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Quality and Safety, 26 (7), 559-568. (doi:10.1136/bmjqs-2016-005567).

Record type: Article

Abstract

Objectives To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care.Design Cross-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.Setting Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland.Participants Survey 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 measures Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction.Results Richer 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.Conclusions A 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.

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Accepted/In Press date: 8 October 2016
e-pub ahead of print date: 15 November 2016
Published date: 1 July 2017

Identifiers

Local EPrints ID: 429856
URI: https://eprints.soton.ac.uk/id/eprint/429856
ISSN: 2044-5415
PURE UUID: 7e1a432b-7ccf-4976-9db3-5ccc9aa96d3f
ORCID for Peter Griffiths: ORCID iD orcid.org/0000-0003-2439-2857
ORCID for Jane E. Ball: ORCID iD orcid.org/0000-0002-8655-2994

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Date deposited: 08 Apr 2019 16:30
Last modified: 15 Aug 2019 00:38

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Contributors

Author: Linda H. Aiken
Author: Douglas Sloane
Author: Peter Griffiths ORCID iD
Author: Anne Marie Rafferty
Author: Luk Bruyneel
Author: Matthew McHugh
Author: Claudia B. Maier
Author: Teresa Moreno-Casbas
Author: Jane E. Ball ORCID iD
Author: Dietmar Ausserhofer
Author: Walter Sermeus

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