Effects of the nursing practice environment, nurse staffing, patient surveillance and escalation of care on patient mortality : A multi-source quantitative study

Background: A favourable nursing practice environment and adequate nurse staffing have been linked to reduced patient mortality. However, the contribution of nursing care processes such as patient surveillance and escalation of care, on patient mortality is not well understood.

Objective: The aim of this study was to investigate the effect of the nursing practice environment, nurse staffing, missed care related to patient surveillance and escalation of care on 30-day inpatient mortality.

Design: A multi-source quantitative study including a cross-sectional survey of nurses, and retrospective data extracted from an audit of medical and admission records.

Setting(s): A large tertiary teaching hospital (600 beds) in metropolitan Sydney, Australia.

Methods: Data on the nursing practice environment, nurse staffing and missed care were obtained from the nursing survey. Patient deterioration data and patient outcome data were collected from the medical and admission records respectively. Logistic regression models were used to examine the association between the nursing practice environment, patient deterioration and 30-day inpatient mortality accounting for clustering of episodes within patients using generalised estimating equations.

Results: Surveys were completed by 304 nurses (84.5 % female, mean age 34.4 years, 93.4 % Registered Nurses) from 16 wards. Patient deterioration data was collected for 30,011 patient deterioration events and 63,847 admitted patient episodes of care. Each additional patient per nurse (OR = 1.22, 95 % CI = 1.04–1.43) and the presence of increased missed care for patient surveillance (OR = 1.13, 95 % CI = 1.03–1.23) were associated with higher risk of 30-day inpatient mortality. The use of a clinical emergency response system reduced the risk of mortality (OR = 0.82, 95 % CI = 0.76–0.89). A sub-group analysis excluding aged care units identified a 38 % increase in 30-day inpatient mortality for each additional patient per nurse (OR = 1.38, 95 % CI = 1.15–1.65). The nursing practice environment was also significantly associated with mortality (OR = 0.79, 95 % CI: 0.72–0.88) when aged care wards were excluded.

Conclusions: Patient mortality can be reduced by increasing nurse staffing levels and improving the nursing practice environment. Nurses play a pivotal role in patient safety and improving nursing care processes to minimise missed care related to patient surveillance and ensuring timely clinical review for deteriorating patients reduces inpatient mortality.

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).