Nursing Complexity and Health Literacy as Determinants of Patient Outcomes: A Prospective One-Year Multicenter Cohort Study

<b>Background/Objectives:</b> Although nursing complexity and health literacy (HL) are critical determinants of patient outcomes, their combined impact on mortality, hospital re-admissions, and emergency department (ED) visits remains poorly understood. This study aims to measure nursing complexity and HL in hospitalized patients, examine their interaction, and analyze their impacts on mortality, hospital re-admissions, and ED visits over a one-year follow-up period. <b>Methods:</b> Adult patients from two hospital centers were enrolled, excluding those with stays under two days or cognitive impairments. Data were collected at baseline to assess nursing complexity (measured according to the number of nursing diagnoses assigned to patients within 24 h from hospital admission) and HL (assessed using the Single-Item Literacy Screener, SILS). Patients were followed during a 12-month follow-up period to track mortality, hospital re-admissions, and ED visits. Latent class analysis classified patients into distinct nursing complexity and HL profiles. Survival analyses and Cox proportional hazard models were used to evaluate the relationships between variables. <b>Results:</b> At baseline, among the 2667 enrolled patients, 55.9% were classified as having high nursing complexity, and 32% had inadequate HL. High nursing complexity was associated with lower HL (r = 0.384; <i>p</i> < 0.001). During follow-up, 387 patients (14.5%) were lost. Of the remaining sample, mortality occurred in 8.3% of the patients, hospital re-admissions in 27.2%, and ED visits in 16.8%. Nursing complexity was significantly associated with higher mortality (HR: 1.84, adjusted HR: 1.81), but not with hospital re-admissions or ED visits. The patients with inadequate HL (32%) had increased risks of mortality (HR: 11.21, adjusted HR: 7.75), hospital re-admissions (HR: 3.61, adjusted HR: 3.58), and ED visits (HR: 20.78, adjusted HR: 14.45). The patients with both high nursing complexity and inadequate HL had the highest mortality risk and the lowest 12-month survival rate (75%; 95% CI: 71.1-79.1%; <i>p</i> < 0.001). <b>Conclusions:</b> This study demonstrates that both high nursing complexity and inadequate HL independently and jointly contribute to adverse patient outcomes. Interventions targeting HL and supporting patients with high nursing complexity could reduce risks, enhance care, and improve patient survival. While these findings underscore the critical role of both factors in patient outcomes, the limitations include this study's single-country setting and reliance on a single-item HL measure. Future research should validate these findings in broader healthcare contexts and integrate multidimensional HL assessments for a more comprehensive evaluation.