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More registered nurses on ward improves inpatient satisfaction, suggests major study

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Perceptions of poor quality hospital care are strongly linked to there being too few nurses on duty, rather than staff being “uncaring”, according to new analysis of patient satisfaction levels in England.

The analysis, which used data from the seminal RN4CAST nursing workforce study, revealed that satisfaction with care in hospitals declined when patients believed there were not enough nurses on wards.

“Patients express a high level of confidence in nurses”

Study authors

Some of the UK’s leading nursing researchers investigated how patients’ perceptions were affected by nurse staffing levels, their confidence in nurses and doctors, and hospital environments.

They noted that NHS workforce initiatives had been brought in recently on the basis of an “unsubstantiated narrative” that problems with quality of care were due to “uncaring” nurses, such as the introduction in 2012 of higher standards for nursing courses in London.

But their findings showed simply that increasing registered nurse staffing levels was more likely to improve patient ratings, said the researchers from King’s College London, the University of Southampton and also the University of Pennsylvania in the US.

The academics analysed data from a 2010 NHS survey of 66,348 patients discharged from 161 acute and specialist NHS trusts in England.

“The narrative that quality deficits in hospitals in England are due to ‘uncaring’ nurses is not supported by the evidence”

Study authors

It is the first quantitative study to use the survey to determine links between patient confidence in nurses and doctors, registered nurse staffing leves and patient experiences with hospital care in NHS hospitals in England.

The study authors found hospital care was rated “excellent” by 57% of patients who said there were “always” enough nurses to care for them – but by only around 27% who “sometimes” had enough nurses.

Meanwhile, just 14% of those patients who reported having “never” or “rarely” enough nurses on duty said they had excellent care, according to the study, published in the journal BMJ Open today.

The researchers also found it was equally important for patient perceptions of care quality to have confidence in both the doctors and nurses treating them.

Their analysis revealed that 60% of patients who trusted both types of clinician said they received “excellent” care. But when confidence in either nurses or doctors was reduced, patient experience went down by virtually the same amount.

“Having more staff on the wards, who have limited qualifications, is not enough”

Peter Griffiths

The researchers found only 16% of patients who were confident in their doctors – but not nurses – rated their care as excellent. Similarly, just 17% of those who trusted their nurses – but not doctors – said they had excellent care.

The academics went on to merge 5,311 responses from the patient survey on medical and surgical wards at 31 trusts with data from the 2010 RN4CAST survey of 2,963 inpatient nurses on the same wards.

They wanted to find out to what extent the level of incomplete care – as reported by nurses themselves – affected how patients rated their experiences.

The survey of nurses looked at 13 elements, including incomplete pain management, missed treatment, and lack of time to talk with patients. It found overall that 27% of staff did not have the time to complete three or four of them.

But this differed across trusts – and where organisations had fewer patients per nurse, the average number of types of missed care also reduced.

A ratio of one nurse to 12 patients was linked to an average of 4.4 types of incomplete care, while a ratio of 1:8 was associated with 3.8 types of missed care, and a 1:4 staffing ratio had an average of 3.2 elements of missed care.

“Improving nurse staffing in NHS hospitals holds promise for improving patient satisfaction”

Anne Marie Rafferty

In addition, the research team found wards with better work environments had fewer types of missed care, such as those with opportunities for nurses to take part in hospital affairs or with good relationships between nursing and medical staf .

By merging the two sets of survey results, the researchers found patients were less likely to report excellent care if there were more types of care missed.

For example, they found in hospitals where an average of 4.5 types of care were missed by a nurse on a shift, there was 22% less chance patients would say their care was excellent, compared with a hospital that had an average of 3.5 incomplete tasks for every nurse on a shift.

“Patients express a high level of confidence and trust in nurses, and their satisfaction with hospital care is less favourable when they perceive there are not enough nurses available,” concluded the study paper – titled Patient satisfaction with hospital care and nurses in England: an observational study.

“The narrative that quality deficits in hospitals in England are due to ‘uncaring’ nurses is not supported by the evidence,” the paper stated.

peter griffiths

peter griffiths

Peter Griffiths

“On the contrary, our findings suggest that reducing missed nursing care by ensuring adequate numbers of registered nurses at the hospital bedside and improved hospital clinical care environments are promising strategies for enhancing patient satisfaction with care,” it added.

One of the study co-authors, Professor Peter Griffiths, from the University of Southampton, said: “The variation in nurse staffing levels between different NHS hospitals is huge.

“When there aren’t enough professional nurses, things get missed, patients notice, and this affects their confidence in the quality of the hospital and the care they receive,” he said. “England has one of the lowest percentages among European countries of professional nurses at the bedside already.

“But having more staff on the wards, who have limited qualifications is not enough – the NHS needs to focus on achieving safe registered nurse staffing levels as a means to achieve better outcomes including improving patients’ satisfaction with their care,” he added.

King's College London

Opinion: ‘Vote remain to make nursing stronger’

Anne Marie Rafferty

“Patient perception is an important barometer of quality of care and confidence in the NHS,” noted Professor Anne Marie Rafferty, from King’s College London, who also co-wrote the paper.

“The widening gap between demand and capacity is reflected in missed care, which in turn is associated with poor nurse staffing and poor hospital environments,” she said. “Improving nurse staffing in NHS hospitals holds promise for improving patient satisfaction.” 

What the study authors concluded

Patients express a high level of confidence and trust in nurses, and their satisfaction with hospital care is less favourable when they perceive there are not enough nurses available. The narrative that quality deficits in hospitals in England are due to ‘uncaring’ nurses is not supported by the evidence. On the contrary, our findings suggest that reducing missed nursing care by ensuring adequate numbers of RNs at the hospital bedside and improved hospital clinical care environments are promising strategies for enhancing patient satisfaction with care.

Source: BMJ Open

As previously reported by Nursing Times, in recent years findings from the RN4CAST and subsequent analysis of its data have revealed a range of significant links between nurse staffing levels and patient safety.

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Readers' comments (1)

  • It is frustrating turn up at work and find out that the ward is 2/3 nurses short and you won't be able to provide the deserved best care to your patients.
    Eventually,other staff will be moved from other wards or an agency nurse will come (somentimes with no clue about patients and ward speciality,which will make permanent staff working for 2).

    Patients rely on us and they most of the time they perceive that we are in control, but in reality having a ratio of 8+patients to 1 nurse is terribly wrong.


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