Nurse staffing skill mix and acuity-adjusted provision ratios in Swedish neonatal care: A cohort benchmark study

The development of neonatal intensive care has substantially reduced infant mortality, still, infants remain at high risk for adverse outcomes. Safe care relies on adequate nurse staffing and an appropriate skill mix, which is especially important in neonatal intensive care as infants are extremely vulnerable to harm when quality lapses occur. Although international guidelines recommend optimal nurse-to-patient ratios for neonatal care, these standards have not been fully implemented, leaving it unclear whether current staffing levels align with recommendations for safe staffing.

To benchmark the acuity-adjusted registered nurse staffing provision ratio in neonatal intensive care and determine the skill mix distribution and variation of nursing staff across shifts.

This retrospective cohort study included infant data from a 16-week period in 2022 in three neonatal intensive care units with a common administration at a university hospital. Data were obtained from the hospital's data repository and the Swedish Neonatal Quality Register, including 609 neonatal admissions and 345 nursing staff members working 1008 shifts. Infants' daily acuity levels were assessed using an adapted version of the British Association of Perinatal Medicine's guideline, classifying infants into three levels: intensive care, high dependency care, and special care. Staffing provision was measured as the number of worked hours per shift, staff category, and unit. The registered nurse provision ratio was defined as the number of registered nurse hours provided divided by the recommended hours. A ratio below 1.0 indicates understaffing.

The population's total in-hospital days were 4674, and the mean birth weight was 2843 g (SD 1029), with 57.0 % being boys. The proportion of registered nurses relative to nursing assistants ranged from 22.2 % to 85.7 %, with a median of 46.5 %. Registered nurses with specialist education accounted for a median of 73.0 % of total registered nurse hours. Within each unit, the mean acuity-adjusted number of registered nurses recommended by the British Association of Perinatal Medicine's standard was relatively consistent across shift types and between weekdays and weekends. However, the required number of registered nurses between individual shifts showed considerable variation, ranging from 2.5 to 10.3. During the inclusion period, 81.2 % of the shifts had a registered nurse provision ratio below 1.0, suggesting that most shifts did not meet the recommendations for staffing levels.

This study highlights a shortfall in registered nurse staffing relative to recommended levels. Ensuring adequate registered nurse staffing levels is crucial for maintaining high-quality neonatal care and improving infant outcomes.