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Diluting hospital nursing skill mix ‘not in the public interest’

Policies should be treated with caution because the consequences can be life threatening for patients, say researchers. 
Skill mix

Implementing policies to dilute hospital nursing skill mix should be treated with caution because the consequences can be life threatening for patients, say researchers.

In a study spanning six European countries, including England, the researchers found that replacing professionally qualified nurses with lower-skilled nursing assistants is linked to a heightened risk of patient death and other indicators of poor quality care.

They analysed data from 13,000 nurses in 243 hospitals, almost 19,000 patients in 182 of these hospitals, and discharge data for more than 275,500 patients who had undergone a surgical procedure in 188 of the hospitals.

The researchers found that for every 25 patients, replacing just one qualified nurse with a nursing assistant was associated with a 21% rise in the likelihood of dying in hospitals with average nurse staffing

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Implementing policies to dilute hospital nursing skill mix should be treated with caution because the consequences can be life threatening for patients, say researchers. 


Replacing qualified nurses with nursing assistants should be approached with caution. Picture: SPL

In a study spanning six European countries, including England, the researchers found that replacing professionally qualified nurses with lower-skilled nursing assistants is linked to a heightened risk of patient death and other indicators of poor quality care. 

They analysed data from 13,000 nurses in 243 hospitals, almost 19,000 patients in 182 of these hospitals, and discharge data for more than 275,500 patients who had undergone a surgical procedure in 188 of the hospitals. 

The researchers found that for every 25 patients, replacing just one qualified nurse with a nursing assistant was associated with a 21% rise in the likelihood of dying in hospitals with average nurse staffing levels and skill mix. 

After taking account of potentially influencing factors, every 10% increase in the proportion of professionally qualified nurses was associated with an 11% decrease in the odds of a patient dying after surgery, a 10% fall in the odds of patient dissatisfaction; and an 11% fall in the likelihood of reports of poor quality care, such as pressure ulcers and falls. 

Nurses were also less likely to experience burnout or be dissatisfied in their jobs in hospitals with a higher proportion of professionally qualified nurses. 

‘Our study adds new and important evidence that diluting hospital nurse skill mix by adding lower-skilled nurse assistants and /or reducing professional nurses is not in the public interest,’ the study authors said. 


Aiken L et al (2016) Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Quality & Safety. doi: dx.doi.org/10.1136/bmj.e1717

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