This month saw the publication of our latest research on nurse staffing levels in the BMJ Open.
In most respects, the findings are not new or surprising: hospitals with fewer nurses tended to have higher mortality rates. So what was new and why is (another) study showing the same thing important?
Well, for one thing, the finding is not entirely obvious. Not all studies have found an association and it is possible – even likely – that medical staffing levels, which tend to be closely related to nurse staffing levels, are more important when looking at mortality rates. This creates a problem as most existing research ignores medical staffing and can therefore be dismissed by those who choose to do so. Our study included staffing by doctors and still showed an association between mortality among medical patients and registered nurse staffing on medical wards.
Perhaps more interesting though is what we didn’t find. We looked at staffing by healthcare support workers (generally healthcare assistants on hospital wards). This is important, given current interest in reconfiguring the nursing workforce, increasing the number of support workers and measuring contact between all ward nursing staff and patients with no regard to professional qualification.
Current policies are based on the presumption that these unregistered staff can support the work of registered nurses and, to some extent, be a substitute for them. It is an appealing solution to shortages of registered nurses and, as a bonus, means using staff who are paid less. But our results give no indication that such substitution is possible with regard to patient safety. In fact some of our findings indicated that hospitals that employed more support workers per bed had higher mortality rates.
Healthcare support workers are essential components of a ward team. I would not suggest this research shows that we should remove them from wards or reduce their numbers, but it does clearly show that any policy that regards registered nurses and support workers as interchangeable, any report that gives “nurse numbers” or “contacts” or “care hours” without regard to professional status is ignoring a vital difference between the roles and capabilities of different workers on the wards.
The recommendation from the recent Carter review of NHS productivity that the NHS adopts a measure of “care hours per patient day” as a method of reporting ward staffing levels is concerning, because it ignores important differences between the contributions of different staff. Our study shows that not all care hours are equal.
Perhaps we do need to explore new roles with increased training and a new cadre of nursing associates (although if this is an answer to the nurse shortage we have to ask if we know where these staff are coming from) but this cannot be done without regard to the risks that are demonstrated in studies such as this. If you consider registered nursing a “treatment” to foster safety in hospital wards, we know it can be effective. If we are to contemplate replacing this with an untested alternative role, there needs to be a rigorous test of safety first, followed by a rigorous trial of effectiveness before routine implementation. This is especially so because we have an evidence base that identifies the possible risks, but none for the benefits.
It seems that the lessons of the Mid Staffordshire inquiries – in which the potential harms of focusing on the financial benefits of staffing change while ignoring the potential harms was clearly demonstrated – are being quickly forgotten. So our study findings may not be entirely new or surprising for many, but they carry a message that still needs to be heard.
Peter Griffiths is chair of Health Services Research, University of Southampton, NIHR CLAHRC (Wessex)