Association of nurse understaffing and limited nursing work experience with in-hospital mortality among patients: A longitudinal register-based study

Background: Although nurse understaffing and limited nursing work experience may affect hospital patients' risk of mortality, relatively little longitudinal patient-level evidence on these associations is available. Hospital administrative data could provide important information about the level of staffing, nurses' work experience and patient mortality over time. Objective: To examine whether daily exposure to nurse understaffing and limited nursing work experience is associated with patient mortality, using patient-level data with different exposure time windows and accounting for several patient-related characteristics. Methods: This longitudinal register-based study combined administrative data on patients (clinical database Auria) and employees (Titania® shift-scheduling) from one hospital district in Finland in 2013–2019, covering a total of 254,446 hospital stays in 40 units. We quantified nurse understaffing as the number of days with low nursing hours in relation to target hours (< 90 % of the annual unit median), and limited work experience as the number of days with a low proportion of nurses with > 3 years of in-hospital experience, and those aged over 25 (< 90 % of the annual unit median). We used two survival model designs to analyze the associations between nurse understaffing and limited nursing work experience and the in-hospital mortality of the patients: we considered these exposures during the first days in hospital and as a cumulative proportion of days with suboptimal staffing during the first 30 days. Results: In total, 1.5 % (N = 3937) of the hospital stays ended in death. A 20 % increase in the proportion of days with nurse understaffing was associated with an increased, 1.05-fold mortality risk at the patient level (95 % confidence interval, 1.01–1.10). The cumulative proportion of days with limited nursing work experience, or the combination of nurse understaffing and limited work experience were not associated with increased risk of death among all patients. However, both indicators of limited nursing work experience were associated with an increased mortality risk among patients with comorbidities (HR 1.05, 95 % CI 1.02–1.08 and HR 1.05, 95 % CI 1.00–1.10, respectively). Conclusions: Nurse understaffing was associated with a slight, but a potentially critical increase in patient in-hospital mortality. Limited nursing work experience was associated with increased in-hospital mortality in a subgroup of patients with comorbidities. Increased use of administrative data on planned and realized working hours could be a routine tool for reducing avoidable in-hospital mortality.