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The Impact of Hospital Nursing Characteristics on 30Day Mortality

Estabrooks, Carole A.; Midodzi, William K.; Cummings, Greta G.; Ricker, Kathryn L.; Giovannetti, Phyllis


Background: Evidence indicates that hospital nursing characteristics such as staffing contribute to patient outcomes. Less attention has been given to other hospital nursing characteristics central to optimal professional practice, namely nurse education and skill mix, continuity of care, and quality of the work environment.

Objective: To assess the relative effects and importance of nurse education and skill mix, continuity of care, and quality of work environment in predicting 30-day mortality after adjusting for institutional factors and individual patients characteristics.

Method: A cross-sectional analysis of outcome data for 18,142 patients discharged from 49 acute care hospitals in Alberta, Canada, for diagnoses of acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke between April 1, 1998, and March 31, 1999, was done. Mortality data were linked to patient demographic and comorbidity factors, institutional characteristics, and hospital nursing characteristics derived from a survey of all registered nurses working in acute care hospitals.

Results: Using multilevel analysis, it was determined that the log-odds for 30-day mortality varied significantly across hospitals (variance = .044, p < .001). Patient comorbidities and age explained 44.2% of the variance in 30-day mortality. After adjustment for patient comorbidities and demographic factors, and the size, teaching, and urban status of the study hospitals in a fixed-effects model, the odds ratios (95% confidence interval) of the significant hospital nursing characteristics that predict 30-day mortality were as follows: 0.81 (0.68–0.96) for higher nurse education level, 0.83 (0.73–0.96) for richer nurse skill mix, 1.26 (1.09–1.47) for higher proportion of casual or temporary positions, and 0.74 (0.60–0.91) for greater nurse-physician relationships. The institutional and hospital nursing characteristics explained an additional 36.9%.

Discussion: Hospital nursing characteristics are an important consideration in efforts to reduce the risk of 30-day mortality of patients.

Carole A. Estabrooks, PhD, RN, is Associate Professor and Principal Investigator, Knowledge Utilization Studies Program, Faculty of Nursing; and Academic Codirector, Centre for Knowledge Transfer

William K. Midodzi, MSc, is a PhD student, Department of Public Health Sciences, and Data Analyst, Knowledge Utilization Studies Program

Greta G. Cummings, PhD, RN, is Assistant Professor, Faculty of Nursing

Kathryn L. Ricker, MSc, is a PhD candidate, Centre for Research in Applied Measurement and Evaluation, Department of Educational Psychology

Phyllis Giovannetti, ScD, RN, is Professor Emerita, Faculty of Nursing; University of Alberta, Edmonton, Alberta, Canada.

Corresponding author: Carole A. Estabrooks, PhD, RN, Associate Professor, Faculty of Nursing, 3rd Floor Clinical Science Bldg, University of Alberta, Edmonton, Alberta, Canada T6G2G3 (e-mail:

This research was funded by the Alberta Heritage Foundation for Medical Research (AHFMR) and was carried out under the direction of Dr. Phyllis Giovannetti, ScD, RN, Principal Investigator. Dr Estabrooks's work is supported by the Canadian Institutes of Health Research (CIHR).

The authors thank Doug Lier, Alberta Cancer Board, and Charles K. Humphrey, Director, University of Alberta Data Library, for their contributions to this study. They also thank Dr. J. Ivan (Jack) Williams, consultant in health service research & epidemiology, and Anastasia A. Mallidou, Faculty of Nursing, for thoughtful reviews on an earlier version of this manuscript. These data were collected as part of the International Study of Hospital and Patient Outcomes (NIH grant RO1 NRO4513, National Institute of Nursing Research, National Institutes of Health), Dr Linda H. Aiken, University of Pennsylvania, Principal Investigator.

Accepted August 25, 2004.

© 2005 Lippincott Williams & Wilkins, Inc.