A study published in the medical journal BMJ Quality & Safety, which was published online on November 15, 2016, analyzed adult acute care hospitals in Belgium, England, Finland, Ireland, Spain, and Switzerland and concluded: “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.”

The study’s stated objective: “To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care.” The study analyzed survey data collected from 13,077 nurses in 243 hospitals, and 18,828 patients in 182 of the same hospitals in the six countries, for 2009 and 2010. The study found the average total nurse staffing-to-patient ratio was 6.1 for every 25 patients, ranging from 2.7 to 13.8 (nursing staff included both professional nurses and nursing assistants).

Of the 18,828 patients surveyed (an average of just over 100 patient respondents per hospital), 54% gave their hospitals low ratings.

Of the 13,077 nurses surveyed (an average hospital had 54 nurse respondents), on average slightly more than one in five nurses rated the quality of care on their hospital unit as poor or fair; an average of 7% of the nurses across hospitals gave their hospital a poor or failing safety grade; one-third indicated that their hospital exhibited a poor safety culture; nearly one in five nurses would not recommend their hospital to friends or family; on average 9% of the nurses reported that pressure ulcers occurred in their hospitals occasionally or frequently; and, 12% and 23% said the same about falls with injury and urinary tract infections, respectively. In the average hospital, almost 30% of nurses scored high on the burnout scale, and a similar percent expressed dissatisfaction with their job.

There were 275,519 surgical discharges from the 188 study hospitals for which patient data were available (an average of 1,466 discharges per hospital). There were 3,569 surgical patient deaths (an average of 19 deaths per hospital during the study period), yielding an average hospital mortality rate of 12.8 per 1,000 discharges.

The study found that nurses in hospitals with a greater proportion of professional nurses (higher skill mix) were less likely to rate the quality of care in their hospital as fair or poor, were less likely to report poor patient safety culture and less likely to have misgivings about recommending the hospital to family members and friends. Additionally, nurses in hospitals with a rich nursing skill mix were less likely to report common adverse patient events such as falls with injuries, pressure ulcers, and urinary tract infections.

The study found that for every 10-point increase in the percentage of professional nurses among all nursing personnel, there was lower odds of mortality, lower odds of low hospital ratings from patients, and lower odds of reports of poor quality, poor safety grades, and other poor outcomes, after adjusting for patient and hospital factors. The study found that each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death.

In the hospitals that participated in the study, 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.

U.S. Versus European Results

The study reported that its results of nursing skill mix in Europe are similar to results obtained in studies of nursing skill mix in the United States. Its four-state study in the U.S. showed 30-day general surgery mortality rates of 1.2% compared with European in-hospital mortality rates of 1.28% (the U.S. patients studied included all adult patients between 20 and 85 while the European patients were 50 and older). The U.S. hospitals have a higher nursing skill mix than Europe, averaging 75% professional nurses, with hospitals ranging from a low of 68% to a high of 83% professional nurses. Hospital nursing skill mix in the European countries studied averaged 66% professional nurses, varying from 41% to 87%. The study’s authors stated that studies in the U.S. have reached similar conclusions to what they found in Europe: that the higher the proportion of professional nurses the better the outcomes for patients.

Source

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