Staffing e skill-mix del personale di assistenza: qualità delle cure e benessere organizzativo in ospedali per acuti italiani

Background Several studies have measured the impact of nursing skill mix and nursing staffing levels on clinical, organizational and economic outcomes but the heterogeneity in approaches to measuring skill-mix variable leads to a lack of consistent evidence (Griffiths et al., 2014). The impact of skill mix on hard outcomes such as mortality has been studied and addressed in scientific literature (Aiken et al., 2017, Blegen et al., 2011, Needleman et al., 2011, Sales et al., 2008, Sochalski et al., 2008) but in Italy no studies were conducted analyzing these relationships. There is a lot of interest in understanding how the mixture of professions may influence clinical and process outcomes and if one staff group could be substituted by another one to achieve cost-effectiveness results. The scoping review conducted for this thesis, as a background of the RN4CAST@IT results, reported that the evidence is consistent in pointing to the benefit of increasing skill mix either through increasing the absolute or relative number of registered nurses in a nursing team that includes registered nurses, lower grades of nursing staff and assistants. Methods We have conducted a large multisite observational cross-sectional study (called RN4CAST@IT) in thirteen regions in Italy, in 2015. A three-levels survey (patient, nurse and organizational level) was performed through paper-based and electronic tools; for this thesis we have analyzed the relationships between nursing staffing levels, skill mix and some of the most important clinical and organizational nursing sensitive outcomes from the nurse-level database using the statistic software “R”. Finally, the relationship between mortality and nursing skill mix was investigated using organizational data. Results Relevant outcomes have significant relationships with nursing staffing levels and nursing skill mixes. For example: nurses in RNstaff2 and RNstaff3 have a risk of declaring its Intention to Leave of 20% and 50%; nurses in RNstaff2 and RNstaff3 have a risk of declaring a condition of poor/fair quality of nursing care of 40% and 70%, respectively, higher than those in situations of RNstaff1. Relationships between nursing skill mix and mortality were studied through 235.007 records of two Italian regions discharged data. In structures with an average skill mix between 0.60 and 0.62 Therefore in hospitalizations with a hospital stay of more than 6 days, the increase in skill mix determines a significant reduction (-34%) in mortality compared to structures that have an average skill mix between 0.55 and 0.59. Discussion and Conclusion Our study has heilightened that better conditions of nursing staffing levels and nursing skill mixes lead to better clinical, organizational and process outcomes. Mortality is one of the most relevant indicators for quality of care; as reported for other countries, also for Italy mortality is less when nursing skill mix is better (with more registered nurse and less health care assistants). These results, for the first time in our country, give the clear and demonstrated need to improve strategies to maintain nursing staff on safety levels to promote quality of care, well-being environment for patient and nurses and to reduce risks of adverse outcomes. As done in other countries, Italian decision makers, university and the government now have the basis on update staffing and skill mix standards for hospitals, nursing homes and all the institutions for acute and chronical patients with in mind that the economic perspectives should be cost-effectiveness in long-time and supporting quality of care.