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Int J Nurs Stud. 2018 Feb;78:10-15. doi: 10.1016/j.ijnurstu.2017.08.004. Epub 2017 Aug 24.

Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study.

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Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet (KI), Stockholm, Sweden; University of Southampton & National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Southampton, United Kingdom. Electronic address:
KU Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium.
Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA.
Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, England, United Kingdom.
LIME Karolinska Institutet, Stockholm, Sweden.
LIME Karolinska Institutet & Innovation Centre, Karolinska University Hospital, Stockholm, Sweden.
Chair of Health Services Research, University of Southampton, & National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Southampton, United Kingdom.



Variation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery.


Examine if missed nursing care mediates the observed association between nurse staffing levels and mortality.


Data from the RN4CAST study (2009-2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses' staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation.


Nurse staffing and missed nursing care were significantly associated with 30-day case-mix adjusted mortality. An increase in a nurse's workload by one patient and a 10% increase in the percent of missed nursing care were associated with a 7% (OR 1.068, 95% CI 1.031-1.106) and 16% (OR 1.159 95% CI 1.039-1.294) increase in the odds of a patient dying within 30days of admission respectively. Mediation analysis shows an association between nurse staffing and missed care and a subsequent association between missed care and mortality.


Missed nursing care, which is highly related to nurse staffing, is associated with increased odds of patients dying in hospital following common surgical procedures. The analyses support the hypothesis that missed nursing care mediates the relationship between registered nurse staffing and risk of patient mortality. Measuring missed care may provide an 'early warning' indicator of higher risk for poor patient outcomes.


Care left undone; Cross-sectional study; Hospital; Mediation; Missed care; Mortality; Nurse staffing; Patient safety; Post-surgical

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