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Research highlights risk of low nursing numbers


The more nurses that a trust employs per bed the fewer of its patients are likely to die or to experience long hospital stays, reveals a major statistical analysis published this week in Nursing Times.

At a time when staffing shortages have been cited as a major factor in why some trusts fail, the study, shows for the first time that increasing NHS nursing workforce numbers can be key to improving quality of care.

While many factors can influence a trust’s outcomes, the model developed by Dr Foster Intelligence, suggests that one of the most important for patient mortality and length of hospital stay is the number of qualified nurses a trust has per bed.

Looking at 147 acute trusts, the researchers compared workforce data with scores for the hospital standardised mortality ratio (HSMR) – an outcomes rating method used by Dr Foster in its annual Hospital Guide – and ratings from the number of long-stay patients.  

The authors found that trusts with a low nurse per bed ratio were roughly twice as likely as those with a high nurse to bed ratio to have an HSMR* rating that was classed as ‘high’, compared with the typical English hospital.

Study author Dr Simon Jones, chief statistician at Dr Foster Intelligence and senior research fellow at the National Nursing Research Unit at King’s College, London, said: ‘It is highly likely that the credit crunch will put pressure on the NHS. This research demonstrates that it is vital for trusts to maintain good levels of qualified staff in order to saf guard patient safety.’

Based on their model, 10 trusts – including two with foundation status – have the lowest nurse per bed ratios and a high HSMR rating (see below in alphabetical order. See attached documents on the right for individual trusts’ statements).

Top ten NHS trusts with high HSMR and lowest nurse/bed ratios

  • Colchester University Hospital NHS Foundation Trust
  • Chesterfield Royal Hospital NHS Foundation Trust
  • Mid Yorkshire Hospitals NHS Trust
  • Northern Lincolnshire & Goole Hospitals NHS Trust
  • Queen Mary’s Sidcup NHS Trust
  • Sherwood Forest Hospitals NHS trust
  • South Warwickshire General Hospitals NHS Trust
  • St Helens & Knowsley Hospitals NHS Trust
  • The Queen Elizabeth Hospital King’s Lynn NHS Trust
  • Walsall Hospitals NHS Trust

Sue James, chief executive for Walsall Hospitals NHS Trust, said: ‘This is the first time we have seen these disparate data being presented together in this way and at face value it is difficult to comment on their validity. 

But she added: ‘We treat the issue of nursing levels very seriously and are fortunate in that we have relatively low rates of staff turnover.’

Denise Hagel, director of nursing/deputy chief executive of Colchester Hospital University NHS Foundation Trust, insisted the trust was not ‘under-nursed’ and that patient safety was its ‘no one priority’.   

She added: ‘In response to the exceptional pressures we experienced over the winter, we have already given an undertaking to expand our bed base and to recruit additional nursing and medical staff.’

Tracey McErlain-Burns, chief nurse and director of patient experience at Mid Yorkshire Hospitals NHS Trust, said: ‘We have a dedicated and hard working nursing workforce and are actively recruiting to vacancies. We have recently enabled most of our senior ward sisters and charge nurses to become supervisory to shifts such that they can oversee and supervise clinical care while providing highly visible leadership.

‘We have also carried out a review across our hospitals and identified areas for prioritised investment in additional registered nurses,’ she added.

A spokesperson for Queen Mary’s Sidcup NHS Trust said it had recently conducted a review of its nurse-to-bed ratio figures. ‘We agree with the Dr Foster figures, but these are averaged across the whole trust, and the number of nurses per bed in high dependency and specialist areas is higher than the figure quoted,’ they said.

However, Glen Burley, chief executive of South Warwickshire Hospitals NHS Trust, questioned whether HSMR was a ‘good indicator of the quality of nursing care’. ‘We have out own patient experience survey that demonstrates 82% of our patients rate their care as “good” or “excellent”,’ he said.

A spokesperson for Northern Lincolnshire and Goole Hospitals NHS Trust, said that, according to the Healthcare Commission’s latest ward staffing survey, the trust’s nurse levels were in line with the national average.

Equally, a spokesperson for St Helens and Knowsley Teaching Hospitals NHS Trust said: ‘The trust has the appropriate number of dedicated and skilled nursing staff to provide the highest quality of care to our patients. The ratio of nursing staff, including HCAs, to each bed is 1.98.

‘As well as this, the trust is committed to developing our existing nursing staff and practices to deliver the best quality of care, with a Productive Wards programme in place to maximise the amount of time nurses spend with their patients and a Wards of Excellence scheme to maintain our high nursing standards,’ they said.

In a statement Chesterfield Royal Hospital NHS Foundation Trust said it ‘continually strives to provide high standards of care’.

‘We reviewed staffing levels last year to ensure we have the right number of staff on our wards, with the right skills to provide high quality nursing where needed,’ it said. ‘On examination, it is clear that these latest figures under-represent the current position at the Royal.’ 

Sherwood Forest Hospitals NHS Foundation Trust said in a statement that it took Dr Foster reports and all national data comparisons ‘very seriously’ and thoroughly investigated any issues raised. 

But it said: ‘The trust feels that calculating a ratio of nurses per bed only has limited value because it includes all qualified nurses in the trust – many of whom do not work on the wards.

‘It is also important to note that our trust has a high number of healthcare staff who are qualified but not registered. These staff provide a valuable contribution to the care provided in our hospitals but are not counted as part of this ratio,’ the statement added.


*The definition of high HSMR in this research is not the same as that for the Dr Foster Hospital Guide. For this research Dr Foster calculated HSMR banding using 95% confidence limits (rather than the 99.8% control limits used in the Dr Foster Hospital Guide) to be consistent with an earlier Dr Foster analysis published in 1999.


Related files

Readers' comments (5)

  • A spokesperson for Queen Mary’s Sidcup NHS Trust -‘We agree with the Dr Foster figures, but these are averaged across the whole trust, and the number of nurses per bed in high dependency and specialist areas is higher than the figure quoted,’ they said.

    Do they think that we are complete idiots?! I expect that most, if not all high dependency and specialist areas have a high nurse:pt ratio. This would therefore make nurse staffing in other areas poor if their overall average is a low nurse:pt ratio. I would be VERY interested to see what their staffing is in non critical care and specialist areas...

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  • I can't stand this any longer....Even when faced with 'evidence' trusts will sqirm and wriggle out of this issue. It has been self evident for many years that nurse patient ratio's make a huge difference to outcomes. But no....they always argue that they have enough!!! Elderly care and general medical, wards are always at the end of the line when it comes to staffing, yet they are the ones with long lengths of stay and delayed discharges and all the other things that go along with prolonged hospital stays. When will the stupid people that 'run' the NHS get their heads out .....and sort this out for all our sakes.
    signed: One fed up nurse!

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  • Exactly anon above, trusts will always find a way to wriggle out of this issue, even with EVIDENCE thrust in their faces!

    It is time Nurses said enough is enough and went on strike!

    Check out the comments on the forum 'should nurses go on strike'.

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  • We will never get the "recommended" number of staff on wards precisley because they are only a recommendation! I have worked too many shifts (including night shifts) without having a break of any shape or form let alone a tea break! and we wonder why staff decide to immigrate to countries that treat nurses better!! I spent a large part of my time writing up and the paperwork increases constantly but does not provide better care. A care plan is only as good as the way it is implemented. More staff right across the nursing profession please, both on the wards and in community. But we know this is never going to happen

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  • forget about it. pace yourself at work and look after yourself. take your break on time and dont stress yourself too much because the TOP ranking officers dont care neither. Friendly advice, go to work and prioritise your task; dont overload your brain with worries that you cant do all things that they expect you to do; go to break on time and dont rush eating your food - forget about the work area; after work, go home on time and relax; play with your kids and spend quality time to your family; DONT tire yourself to much, spare some energy and time for your family because they are the one that matter most NOT the hospital or your BOSS TARGETS.

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