Having too few trained nurses on hospital wards is linked with a daily 3% increase in the risk of patient death, which does not reduce when staffing gaps are plugged with nursing assistants, new UK research has found.
While unregistered nursing assistants may have a key role in ensuring safe care, “they cannot act as substitutes for registered nurses”, conclude those behind the study published in the journal BMJ Quality & Safety.
“While nursing care assistants have an important part to play…they cannot act as substitutes for registered nurses”
The findings also demonstrate the importance of taking action to address nursing staff shortages and boost retention, said the authors.
A research team, led by the University of Southampton, analysed staffing data from 32 wards at one large acute trust in the South of England between April 2012 and March 2015 to look at the impact of skills mix.
During this period, more than 138,000 adult patients spent at least one day on medical and surgical wards with most – 79% - admitted as emergencies.
Staffing levels were measured as hours per patient per day with staffing levels across all wards averaging 4.75 hours for nurses. Meanwhile, average staffing levels for nursing assistants came in at 2.99 hours.
However, the data shows nurse and nursing assistant staffing levels regularly fell below average. During the first five days of their hospital stay patients experienced nearly two days of staffing shortfalls on average.
During the study period, the overall death rate was just over 4% with 5,662 deaths in total.
Researchers found the risk of patients dying increased when there was a shortfall in nurses but decreased with more nursing care.
However, the same was not true for nursing assistants with low and higher levels of nursing assistant staffing linked to increased mortality.
Analysis of the data showed the odds of dying rose by 3% for each day a patient spent with below average nurse staffing levels for that ward.
On days when the number of admissions for each registered nurse was substantially higher than usual – more than 25% above average – this was associated with a 5% increased risk of death. However, there was no significant link between admissions per nursing assistant and risk of death.
Meanwhile, every additional hour of care provided by a registered nurse was linked to a 3% reduction in the chances of dying. However, no such impact was apparent for additional hours of care provided by nursing assistants.
“Patients are paying the highest price for the shortage of nurses”
Dame Donna Kinnair
In order to provide one extra hour of nursing care per patient per day a hospital would need to employ one extra nurse on every shift for a 24-bed ward, suggest the authors.
For patients with a middling length of stay that would add up to 2.7 extra hours of nursing care and potentially an 8% reduction in risk of death, according to their calculations.
While they can’t draw any conclusion about cause and effect, they say their findings are in line with other research that suggests increased nurse staffing is linked to higher quality care with reduced risk of harm or death.
They also suggest that policies designed to boost the nursing support workforce – such as the development of the new nursing associate role - won’t solve problems linked to widespread shortages of nurses.
“These findings show the potential consequences of shortages of registered nurses in terms of the negative impact on patient safety,” said the paper.
“While nursing care assistants also have an important part to play in maintaining the safety of hospital wards, they cannot act as substitutes for registered nurses.”
When assessing staffing requirements or making comparisons, registered nurse and nursing assistant hours “should not be treated as equivalent”, the paper adds.
“Strategies to improve the supply of registered nurses are required,” it concludes. “The adverse consequences of registered nurse shortages are unlikely to be remedied by increasing the numbers of lesser trained nursing staff in the workforce.”
It comes as latest figures showed there were 40,877 nurse vacancies in the NHS in England in the second quarter of 2018/19 - an increase from 39,154 in the same period last year.
A new report on university data also revealed a continuing decline in students studying nursing in the country.
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Responding to the findings, Dame Donna Kinnair, acting chief executive and general secretary of the Royal College of Nursing, said: “As the official count of vacant nurse jobs rises this year, this study shows the death count will too - it’s as stark as that.
“The government and the NHS in England must pull together to resolve the staffing crisis - patients are paying the highest price for the shortage of nurses,” she added.
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Source: Kate Stanworth
Dame Donna said the research was the latest in a “long line of studies” that showed patient safety was at risk from failures in long-term workforce planning.
She renewed calls from the RCN for an additional £1bn to invested into nursing higher education and for safe staffing to be enshrined in law.