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Study finds 16% higher mortality risk with 10% increase in missed care by nurses

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Uncompleted nurse care has been pointed to as the “missing link” that explains why hospitals with lower nurse staffing levels are associated with a higher risk of patient death, according to a new study.

Emerging findings from Southampton University research have, for the first time, found a “significant association” between missed nurse care and an increase in risk of patient death, which has helped to unlock the explanation for the link between mortality rates and staffing levels.

“This new research has an important role in identifying that missing link [between nurse staffing and mortality rates]”

Jane Ball

A 10% increase in the amount of care left undone by nurses was associated with a 16% increase in the likelihood of a patient dying within 30 days of admission for a common surgical procedure, according to the study, called Post-operative mortality missed care and nurse staffing in nine countries.

Examples of care left undone were taken from a list of 13 tasks, including patient surveillance, administering medicine on time, adequate documentation, comforting patients, skin care, and pain management.

Previous research has already shown both that lower nurse staffing levels are associated with more instances of care not being completed, and with higher risk of patient death.

“The research keeps on saying you cannot afford to think that substitution is an option, because the data says it isn’t”

Jane Ball

Through additional statistical analysis as part of this latest study, academics went on to show care left undone provided a “plausible causal pathway” between lower nurse staffing levels and higher patient mortality.

The findings come from further investigation of the major RN4Cast study of nurse staffing at hospitals in nine European countries, including 31 NHS acute trusts in England.

The RN4Cast data includes information from 2010 on 422,730 surgical patients at 300 general acute hospitals, and a survey of 26,516 registered nurses.

Results from the latest analysis have yet to be published in full. However, in a summary paper, the lead researcher described the findings as “striking”.

“For the past 20 years we didn’t have a theoretical explanation for how or why it could be that nurse staffing affects mortality,” said Southampton principal research fellow Jane Ball .

“Given that we knew about that relationship and also that with lower staffing there was a higher risk of care not being completed, the one thing we hadn’t tested before was whether care left undone has a relationship with mortality,” she said.

“That finding is important for its own sake – because it goes to show that patients require more complete care and that when we scrimp on the completeness of that care we put patients’ lives at risk,” she told Nursing Times.

“But we then went on in our analysis to see if that provides an explanation of how it is that registered nurse staffing levels have a relationship to mortality – and we found that care left undone is a mediator,” she added.

“Building on the evidence before, this new research then has an important role in identifying that missing link,” said Ms Ball.

University of Southampton

Jane Ball

Jane Ball

She acknowledged that the missed care data was based on a survey of nurses – as opposed to electronic records – and was also from one shift, which meant it only provided a snapshot.

But she said that in addition to previous studies – including another due to be published soon by colleagues at the University of Southampton, which has found a direct link between low nurse staffing and death rates – the findings provided a “compelling case” that fewer nurses caused poorer outcomes.

“This study reinforces the importance of registered nurse staffing,” she said, adding that her previous research had shown that even when more healthcare assistants had been on shift during periods with fewer nurses, the amount of care left undone remained higher.

“The research keeps on saying you cannot afford to think that substitution is an option, because the data says it isn’t. Having more support workers isn’t a solution to not having enough registered nurses,” she said.

As reported yesterday by Nursing Times, emerging findings from another new study, thought to be the first of its kind in England, suggest the risk of a patient dying increases “significantly” following a period in hospital during which the number of nurses falls below the required level.

However, further research was required to provide a deeper explanation as to why patients were at risk of dying unnecessarily following missed care as a result of lower nurse staffing, said Ms Ball.

She suggested one interpretation was that it was purely because the fundamental aspects of care – those tasks that were key to a patient’s recovery – were being missed.

But another could be that nurses who repeatedly work in understaffed environments become used to not completing care, meaning they are no longer as able to spot signs of deterioration.

“Is it possible that the context of what it’s like to work in a particular hospital day-in and day-out sets a different starting point for how your shift-by-shift staffing affects you?,” she suggested.

“When you read those reports [from the Francis inquiry] you get the feeling it was not simply about what wasn’t done in terms of the activity”

Jane Ball

“So, if you have low staffing as a one-off, but overall it’s quite a well-staffed hospital that is used to escalating things when there is a problem and is reactive to it, how does that compare to somewhere that is permanently running at a 10-15% nurse vacancy?” said Ms Ball.

“I wonder what we would have found if Mid Staffordshire had been one of these sites and we’d looked in much more detail…When you read those reports [from the Francis inquiry] you get the feeling it was not simply about what wasn’t done in terms of the activity, but the whole shift in mind-set,” she noted.

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