A quantitative systematic review of the association between nurse skill mix and nursing‐sensitive patient outcomes in the acute care setting

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.

The effect of nurse staffing on patient‐safety outcomes: A cross‐sectional survey

“…However, no causal inferences or pooled results were conclusive due to considerable heterogeneity in the studies' methods (Mitchell et al, 2018). Another systematic review (Twigg et al, 2019) reported an significant inverse relationship between nurse skill mix and patient outcomes. In this review, significant inverse relationship between pneumonia and infections and nurse skill mix was mentioned in fewer than 50% of the included studies: six of 13 studies and six of 15 studies, respectively.…”

“…Similar findings have been found in other studies (Chang, Yen, Chang, & Liu, 2017; Kim & Bae, 2018). The indices of nurse staffing commonly used in studies are the number of nurses (e.g., the nurse‐to‐patient ratio and nursing hours per patient day) and skill mix (e.g., usually defined as the proportion of RNs or percentage of nursing hours provided by RNs) (Jacob, McKenna, & D'Amore, 2015; Twigg, Kutzer, Jacob, & Seaman, 2019). Comparatively nurses’ education, work experience and the professional–technical structures of the staff have seldom been examined (Audet, Bourgault, & Rochefort, 2018; Jacob et al., 2015).…”

“…The indices of nurse staffing commonly used in studies are the number of nurses (e.g., the nurse-to-patient ratio and nursing hours per patient day) and skill mix (e.g., usually defined as the proportion of RNs or percentage of nursing hours provided by RNs) (Jacob, McKenna, & D'Amore, 2015;Twigg, Kutzer, Jacob, & Seaman, 2019).…”

Acuity, nurse staffing and workforce, missed care and patient outcomes: A cluster‐unit‐level descriptive comparison

“…Non‐linear relationships among acuity, nurse staffing and workforce, missed nursing care (MNC) and patient outcomes are still not completely understood. The need to identify the levels of nursing staff that should be offered to warrant safe nursing care, contributing to achieve patient outcomes, is a major issue in the nursing agenda (Twigg, Kutzer, Jacob, & Seaman, 2019).…”

The association between community mental health nursing and hospital admissions for people with serious mental illness: a systematic review

“…It is surprising that there have been so few relevant studies at a time when nursing workforce research in general settings has been the focus of a number of important and influential studies [30] and reviews [31]. It is also noteworthy that the studies included in our review were all from the UK.…”