Abstract
BackgroundGrowing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Current research is limited to studies using hospital level data or without proper adjustment for confounders which makes the translation to practice difficult.MethodIn this observational study we analysed retrospectively the control group of a stepped wedge randomised controlled trial concerning 14 medical and 14 surgical wards in seven Belgian hospitals. All patients admitted to these wards during the control period were included in this study. Pregnant patients or children below 17 years of age were excluded. In all patients, we collected age, crude ward mortality, unexpected death, cardiac arrest with Cardiopulmonary Resuscitation (CPR), and unplanned admission to the Intensive Care Unit (ICU). A composite mortality measure was constructed including unexpected death and death up to 72 h after cardiac arrest with CPR or unplanned ICU admission. Every 4 months we obtained, from 30 consecutive patient admissions across all wards, the Charlson comorbidity index. The amount of nursing hours per patient days (NHPPD) were calculated every day for 15 days, once every 4 months. Data were aggregated to the ward level resulting in 68 estimates across wards and time. Linear mixed models were used since they are most appropriate in case of clustered and repeated measures data.ResultsThe unexpected death rate was 1.80 per 1000 patients. Up to 0.76 per 1000 patients died after CPR and 0.62 per 1000 patients died after unplanned admission to the ICU. The mean composite mortality was 3.18 per 1000 patients. The mean NHPPD and proportion of nurse Bachelor hours were respectively 2.48 and 0.59. We found a negative association between the nursing hours per patient day and the composite mortality rate adjusted for possible confounders (B = − 2.771, p = 0.002). The proportion of nurse Bachelor hours was negatively correlated with the composite mortality rate in the same analysis (B = − 8.845, p = 0.023). Using the regression equation, we calculated theoretically optimal NHPPDs.ConclusionsThis study confirms the association between higher nurse staffing levels and lower patient mortality controlled for relevant confounders.
Highlights
Growing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality
This study confirms the association between higher nurse staffing levels and lower patient mortality controlled for relevant confounders
The most important limitation in current research is that the majority of studies investigating nurse staffing and patient outcomes use aggregated hospital level data making the translation to the ward level impossible
Summary
Growing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Insufficient staffing leads to the rationing of time to care, which has an important impact on the occurrence of missed care [4] This could be an explanatory factor linking nurse staffing levels and patient outcomes such as in-hospital death [5]. The most important limitation in current research is that the majority of studies investigating nurse staffing and patient outcomes use aggregated hospital level data making the translation to the ward level impossible. It remains unclear which methodology is appropriate when measuring nurse staffing and workload [13]. The objective of this study was to explore the relation between nurse staffing levels and patient mortality on medical and surgical wards considering nurse’s education level, team composition, patient’s age and comorbidity
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