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Higher ratio of HCAs linked with increased mortality


New research into staffing levels within NHS hospitals has suggested a link between a higher proportion of healthcare assistants per patient and a rise in mortality.

In contrast, the study, which looked at 137 acute NHS trusts between 2009 and 2011, found an association between higher numbers of nurses and doctors per patient and a reduction in mortality.

“This research clearly shows us that you can’t regard registered nurses and healthcare assistants as interchangeable”

Peter Griffiths

The research comes as the NHS prepares for a new non-registered nursing associate role and a new care hours metric calculated by mixing HCAs and registered nurses together, which was recommended by last week’s Carter Review.

Professor Peter Griffiths, chair of health services research at the University of Southampton, which carried out the study alongside King’s College London, said trusts that employed more HCAs relative to the number of beds had an increased risk of mortality. The risk of death decreased by 7% for every additional bed per HCA.

For doctors the mortality risk increased by 8% for every additional medical bed and by 13% for every additional surgical bed.

In a smaller sample of 31 trusts, the study considered the number of patients per ward nurse and concluded death rates were 20% lower on medical wards with six or fewer patients per nurse, compared with wards where there were more than 10 patients per nurse.

Peter Griffiths

Peter Griffiths

Peter Griffiths

On surgical wards the results were similar, with higher registered nurse to patient ratios associated with a 17% lower inpatient death rate.

Professor Griffith said: “This research clearly shows us that you can’t regard registered nurses and healthcare assistants as interchangeable when it comes to maintaining safety.

“Everything that we know about nurse staffing levels tells us that you need to consider the two groups separately when determining the numbers of staff required on wards,” he said.

“Any measure that mixes the two can hide dangerous understaffing of registered nurses,” he said. ”This adds to a growing body of research that shows that dilution of the skill mix in the nursing workforce is associated with worse outcomes for patients.”

“Patients should not be asked to pay the price of receiving care from a less skilled and less educated member of staff”

Jane Ball

The research, published in the journal BMJ Open, calculated the predicted number of deaths for medical and surgical inpatients, taking account of influential factors, such as age, other underlying conditions, and number of emergency admissions during the previous 12 months.

The registered nurse headcount varied by as much as a factor of 4 between trusts at the top and bottom of the staffing scale. Even after taking account of all nursing staff, this variation only dropped to a threefold difference between those with the highest and lowest nurse headcounts.

Jane Ball, principal research fellow at University of Southampton, said: “When determining the safety of nurse staffing on hospital wards, the level of registered nurse staffing is crucial; hospitals with higher levels of healthcare support workers have higher mortality rates.

University of Southampton

Jane Ball

Jane Ball

“Patients should not be asked to pay the price of receiving care from a less skilled and less educated member of staff, just to make up for the failure of the system to ensure enough registered nurses,” she said.

”Staffing decisions need to be made on the basis of patient safety, not on the basis of finance. Current policies geared towards substituting [these] workers for registered nurses should be reviewed,” said Ms Ball.

Anne Marie Rafferty, professor of nursing policy at King’s College, London, added: “This is the first study to shed light on the policy of shifting the safe staffing policy decision from nursing to that of the clinical team. It flags the need for caution and the dangers of simply substituting healthcare support staff for qualified nursing staff.”

Janet Davies, chief executive and general secretary of the Royal College of Nursing, said: “This important study adds weight to the growing evidence showing a direct link between the number of available registered nurses and patient experience and outcomes.

“The evidence is a clear warning about the impact on patient care and outcomes if we are to have too few registered nurses or are substituting them for healthcare support workers,” she said.

“Health care support workers are highly valuable staff but they need to complement the registered nursing workforce – not replace it,” she said. ”Health services need to work towards achieving the best overall mix of skills – it could make the ultimate difference for patients.” 


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Readers' comments (25)

  • michael stone

    I've just downloaded the paper - by coincidence on page 1 I spotted:

    'However, despite the apparently strong evidence base, the implications of the findings remain contested by many and there remains significant resistance to mandated ratios from politicians and healthcare providers in many countries.'

    I commented in a BMJ rapid response only yesterday:

    'I find the idea of 'evaluation' of complex health systems interesting: presumably, in the real world this amounts to a comparative evaluation between two or more different health systems [or different 'health system models']. So you would end up with which is 'better', but not a description of 'the best possible system', from such an evaluation.

    My instinct is to question the application of such understanding, even if the methodology of the evaluation is robust: because most health systems are much influenced by politicians, and politicians are not known for 'simply following the evidence', are they ?'

    If your measure is mortality, then it seems logical that nurses and doctors will be more effective in preventing that, than HCAs - because, presumably, nurses and doctors will spot 'something seems to be going very wrong here' faster. In much the same way, that you might expect a better diagnosis of a heart problem from a consultant cardiologist, than from a GP.

    But, mortality might be an extreme case: if the metric was something else [for example, length of stay between admission and discharge] the relative importance of 'basic care' compared to 'clinical expertise' might turn out to be different. If nurses cost more per staff member than HCAs, who is at the moment sure, were some metrics aside from 'mortality' being measured, that the best balance between RGN and HCA numbers isn't significantly different (from the answer you get if mortality is the metric) ?

    Of course, many 'metrics' defeat the reality of data analysis, because whereas it is comparatively easy to discover mortality figures, quite often the data for the parameter you would like to analyse, simply isn't available.

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  • Strange habit you have michel stone, commenting in professional journals on subjects you are not even qualified in! Do you do the same for, sports, cars and other subjects or are you feeding a fetish for nurses, which is what it seems!

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  • I take your point MS, but mortality is the metric government is using to push for, eg, 7 day services, so it's relevant in the context of gov policy. They conveniently see it as relevant for 7DS but will forget its relevance when it comes to safe staffing. Jeremy Hunt seems to have done a complete about-turn on another point - student nurses having to have care experience before they started training which he was so insistent on post-Francies - but now with the removal of the bursary with the idea that that will bring 10,000 more student nurses a year, it's a 'come one, come all' policy.

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  • Well this isn't rocket science is it? but it all comes down to finance and that is why there is so much opposition and posturing. My son has complex medical needs and we hardly dare leave him on a ward because of the poor care he has received previously with not enough qualified and EXPERIENCED nursing staff. The HCA may be excellent at providing the things that make patients comfortable but they are not qualified to notice that the patient is developing jaundice due to drug reactions or check the height of external shunt drainage systems when the patient has moved position. Patients lives matter more than this repeated academic quarrelling. It is crystal clear from this side of the fence!

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  • My daughter has learning difficulties and even the nurses panic if I try to leave the ward!

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  • Sadly to say carers do not have the depth of knowledge required to manage complex conditions but the will to excel and do their best for the patient is there. Maybe the cadet type training isn't such a bad idea after all combining practical hands on with theory

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  • Unfortunately Nurses in my experience are often seen as interchangeable with wards and community teams not having the right or safe skill mix on given shifts with the oft repeated comment from managers that "its ok I will get a spare HCA to help"

    This does not cut it and is dangerous

    I am glad that the Welsh Assembly has the balls to state and mandate safe levels of registered staff

    As for Mr Stone...

    Respectfully it would seem that his comments serve only to obfuscate the issue ans expound his knowledge and wordplay

    It does not add light but rather heat to the situation and removes what is a very pertinent real world situation to a dry academic argument

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  • It's like comparing apples and oranges...

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  • Nurses are continually being criticised for not being hands on enough, not being skilled enough, not being compassionate enough etc. Is it really surprising when we are being removed further and further from the floor and replaced by the more affordable care assistants. Don't get me wrong our carers should be highly valued (and paid more) for the often difficult job they do but they shouldn't be replacing qualified nurses. it can only lead to poorer clinical outcomes when the clinical nurses are pushed into more and more administrative roles with less patient time. As a group I really think we need to stand back and consider when we are going to stand up to the bureaucrats and say enough is enough - I became a nurse to care for my patients not fill in endless paperwork, have my skills given away to other staff and tell someone else to provide comfort and support to the people assigned to my case load. I am sure patients would appreciate having their nurse on the floor more often than in the office too!

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  • As a highly qualified and very experienced RN, I find i spend more time office based and HCA's doing clinical work.
    It needs to be the other way around surely?
    Patient mortality and RN numbers were highlighted in the Black report in the 1980's. It was 'hidden' in the media by politicans, just as the Francis recommendations are today. If a powerful legal man like Sir Robert Francis can't show the Govt how necessary RN's are to patient care, (after the Stafford enquiry) what chance has the nursing profession got in influencing this?!
    The BMA are a powerful organisation as the RCN is 'toothless' and see how junior doctors ar being treated!! We as RN's dont stand a chance. We're being reduced by natural wastage (eg retirement) or people are leaving to work abroad, or younger people dont want to become nurses. The answer? People with a social science degree are being 'trained' in their relevant speciality, and 'updated' with bits of training here and there. There is no 'overall understanding' of medical conditions, nor is there an understanding of any condition which 'doesnt fit' the area patients are given a bed for! eg elderly medical patients in a surgical bed, or a surgical pt in a CCU bed (yes it happens even now!)
    Its a complete mess and all in the name of privatisation which is the total aim here....create chaos and say its a mess lets privatise it. then give a health leader like the beligerant Jeremy c..... sorry, er,..hunt. The NHs is going. Face facts and its the agenda the Govt are pushing hard on now and theyve got their way. RIP NHS.

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