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Diluting nursing skill mix linked to higher patient mortality risk, finds major study

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Diluting nursing skill mix in hospitals is “not in the public interest”, say researchers who found replacing qualified nurses with nursing assistants was linked to an increased risk of patients dying.

Their conclusion comes from a major new European study looking at the impact of skills mix on the quality of care, which is published today in the journal BMJ Quality and Safety.

“Diluting hospital nurse skill mix… is not in the public interest”

Study authors

For every 25 patients, replacing just one professional nurse with a nursing assistant was associated with a 21% increase in the odds of dying in a hospital compared with average nurse staffing levels and skill mix, the researchers found.

Substituting nurses also meant patients were more likely to experience poor care more generally, according to the study, which spanned six different countries.

The findings have prompted the researchers to urge caution on policies to reduce nursing skill mix, “because the consequences can be life threatening for patients”.

“Our study adds new and important evidence that diluting hospital nurse skill mix by adding lower skilled nurse assistants and/or reducing professional nurses is not in the public interest,” concluded the study authors.

The warning comes amid efforts to develop the new nursing associate role in England to sit somewhere between healthcare assistants and qualified nurses, in order to both boost the role and skills of support staff and also help address staffing shortages. But has prompted some concerns about workforce dilution.

The researchers suggested hospital managers and policymakers who wanted to get the best value for NHS money would be better off increasing the proportion of qualified nurses, as well as tackling variations in skill mix between hospitals.

The new study was based on analysis of a range of quality data from acute hospitals in England, Ireland, Belgium, Spain, Finland and Switzerland

Researchers drew on survey responses from just over 13,000 nurses working in more than 240 hospitals, plus responses from patients at more than 180 of those settings.

They also examined discharge data for more than 275,000 patients who had undergone a surgical procedure.

Their calculations, which involved working out the skill mix for each hospital in the study, found wide variations.

“It’s vital this is not ignored as the new nursing associate role is developed”

Janet Davies

The average nursing staff to patient ratio was six for every 25 patients but ranged from 2.5 to around 14. Meanwhile, the average percentage of professional nurses was 66% but this ranged from 41% to 87%.

The research team – which included leading nursing workforce experts from King’s College London and Southampton University – found a higher proportion of qualified nurses was associated with a significantly lower risk of death, higher levels of patient satisfaction and fewer reported incidents of poor quality care such as bedsores, falls and urinary infections.

Taking other factors into account, every 10% increase in the proportion of qualified nurses was linked with an 11% drop in the odds of a patient dying after surgery.

Every 10% increase in the proportion of nurses was also linked to a 10% decrease in the likelihood patients were not happy with their care and an 11% drop in poor quality care being recorded.

In addition, the study found that in hospitals with a higher proportion of qualified nurses those nurses were less likely to experience burnout or be dissatisfied with their jobs.

However, the academics stressed that their research was an observational, snapshot study so it was not possible to draw firm conclusions about cause and effect.

Royal College of Nursing

Pay rise above 1% ‘needed to ease nurse crisis’

Janet Davies

In response, the Royal College of Nursing said the research reinforced the “stark fact” that having the right number of nurses was essential to safe, high quality care.

“Substituting registered nurses with support staff quite simply puts patient care and patients’ lives at risk,” said RCN chief executive and general secretary Janet Davies.

“It’s vital this is not ignored as the new nursing associate role is developed,” she said.

“Support staff are crucial in delivering patient care and the NHS could not operate without them but they cannot and must not become a substitute for registered nurses,” she added.

The latest research was carried out by members of the influential RN4CAST Consortium, which has published a series of high profile nursing workforce studies in recent years.

It was led by Dr Linda Aiken, from the University of Pennsylvania school of nursing in the US, with the UK represented by Professor Peter Griffiths, from the University of Southampton, and Professor Anne Marie Rafferty and Jane Ball from King’s College London.

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Readers' comments (3)

  • Don't get me wrong I enjoy working with Health Care assistants, Clinical support Worker, Nursing assistant or Nurse associate or whatever names they choose to call them each trusts has different titles. Some of my experience were learnt from HCAs to which I am very grateful. Some of them are now retired and were are lifelong friends because I appreciated what they have taught me. However I do not think those HCA's that I have worked with over the years would want to take on roles that they are 1. not paid for or 2. put patients at risk. My other point of view is this nurses are trained in specific way we are trained to detect, assess, plan, implement and evaluate. And as I am a more experience nurse I anticipates a doctors next move. Meaning as soon as I see a patient comes through our doors and I know what the symptoms are I with get the treatment trolley waiting and ready to act. A health care assistant may not have the underpinning knowledge to act this way. I know this because this is what I witness every day. Therefore the right skill mix is important it may included an adequate amount of HCA but they should not be a substitution.

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  • Do you need all these studies to understand something that is so clear and simple?
    It's time we stop hiding behind the curtains.

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  • This is news? Please! Nurses have been aware of this for decades. I once stopped a locum Dr from giving an intravenous bolus of Potassium; would an associate have the knowledge, expertise or, frankly, the guts to do that? Probably not.

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