Research has demonstrated for decades that lower RN staffing levels are associated with higher case mix-adjusted mortality rates. When RN staffing is low, nursing care is more likely to be missed because of lack of time. Although some researchers have suggested that missed care may explain the observed relationship between RN staffing and patient mortality, this hypothesis had not been adequately tested. An observational study conducted in 300 hospitals in nine European countries examined the relationship between RN staffing, missed care, and mortality.

Data on more than 422,000 patients age 50 or older who underwent common general, orthopedic, or vascular surgery at one of these hospitals were combined with data from a survey of more than 26,000 RNs at these same hospitals. Nurses were asked to identify from a list of 13 activities those they believed were necessary but had left undone on their last shift owing to lack of time. Across the nine countries, an average of 26% of necessary nursing care activities were reported as missed on the last shift.

The researchers found that a one-patient increase in a nurse's workload was associated with a 7% increase in the odds of a patient dying within 30 days of admission, and that each 10% increase in missed care was associated with a 16% increase in the odds of a patient dying within 30 days of admission. Each 10% increase in the number of nurses with a bachelor's degree lowered the likelihood of patients dying within 30 days of admission by 7%. In this study, the presence of more nurses with bachelor's degrees was associated with lower postoperative mortality rates, even when there was missed care.

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