Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients

BMJ Qual Saf. 2021 Jan;30(1):46-55. doi: 10.1136/bmjqs-2019-010534. Epub 2020 Mar 27.


Background: There are known clinical benefits associated with investments in nursing. Less is known about their value.

Aims: To compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks.

Methods: Retrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital's size category, teaching and technology status, and were closely matched on comorbidities and other risk factors.

Results: Patients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources.

Conclusion: Hospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.

Keywords: health services research; nurses; patient safety.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Female
  • Hospitals
  • Humans
  • Male
  • Nursing Staff, Hospital*
  • Retrospective Studies
  • Workplace