Abstract
AimsTo examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.DesignA quantitative systematic review included studies published in English between January 2000 – September 2018.Data sourcesCochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix‐methods designs were included if the quantitative component met the criteria.Review methodsThe Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy‐five percent or more of studies with significant results found this association.ResultsSixty‐three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure‐to‐rescue; pneumonia; sepsis; urinary tract infection; mortality/30‐day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.ConclusionNursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.ImpactSkill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.
Highlights
In their report in the year 2000, the World Health Organization highlighted both the importance and the challenges associated with finding the right mixture of healthcare personnel to achieve the best possible outcomes with the staffing resources available (World Health Organization, 2000)
The present review aims to expand on previous research by examining more recent studies up to 2018 exploring the impact of nurse skill mix on patient outcomes
It was hypothesized that changes in skill mix, for example, fewer Registered Nurse hours, affect the processes of care which in turn may impact on patient outcomes
Summary
In their report in the year 2000, the World Health Organization highlighted both the importance and the challenges associated with finding the right mixture of healthcare personnel to achieve the best possible outcomes with the staffing resources available (World Health Organization, 2000). A system‐ atic review and meta‐analysis published in 2007 for example (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007), which analysed nurse staff‐ ing levels, focussed on the ratio of Registered Nurses (RNs) to patients and patient outcomes, but not on nurse skill mix Despite these efforts, clear evidence‐based guidelines on staffing levels are lacking, in regard to skill mix (Brennan, Daly, & Jones, 2013; Sharma, Hastings, Suter, & Bloom, 2016). Of additional concern, continuing economic constraints and impending nursing shortages worldwide have led to the increased deployment of less qualified and unregulated health professionals, leading to changes in skill mix in the configuration of the nursing teams (Jacob et al, 2015; Roche, Duffield, Friedman, Dimitrelis, & Rowbotham, 2016) This is despite at least one study finding in‐ creases in unregulated workers has been associated with poorer patient outcomes (Twigg et al, 2016). The outcome of the review may help inform staffing policy in regard to skill mix changes
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