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
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.