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Who cares? To understand nurses’ impact on safety we need data that includes skill mix

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With its tendency to grab leaders’ attention to the extent that they can do little else, the workforce shortage is starting to feel like the nursing profession’s very own Brexit.

Practically every conversation about policy or strategy seems to conclude that little can be done until the shortage has been addressed, yet a series of decisions have been made that look like deliberate attempts to prevent that from happening. Again, just like Brexit.

So I make no apology for talking about the nursing shortage again – it’s the biggest problem in healthcare. And the latest findings from the University of Southampton team studying nurse staffing make that abundantly clear.

“This finding highlights the important contribution of nursing assistants, but also that they cannot be used instead of nurses”

In a paper published in BMJ Quality & Safety and summarised by Nursing Times the team highlight the effect on patients of being on a hospital ward with too few registered nurses.

In a retrospective observational study using routinely collected data on over 138,000 patients, the risk of death was increased by 3% for every day a patient spent on a ward with below mean numbers of registered nurses (mean was 4.75 nurse and 2.99 nursing assistant hours per patient day – a skill mix of 61% registered nurses).

Conversely, patients’ risk of death decreased when they spent their first five days in hospital on a ward with above mean numbers of registered nurses.

The Southampton team has published huge amounts of data demonstrating conclusively that an adequate number of nurses is crucial for patients’ safety and survival – although policymakers have generally failed to acknowledge it.

But this latest report also makes it very clear that safety is related specifically to registered nurses, and that nursing assistants do not have the same positive impact. The study found that patients’ risk of death increased if they were exposed to either below- or above-average levels of nursing assistant staffing.

This finding highlights the important contribution of nursing assistants, but also that they cannot be used instead of nurses.

The authors point out that the NHS has begun to use a standard metric of ‘care hours per patient day’, which combines registered nurses and nursing assistants into a single measure.

“It is vital that the data specifies who is providing nursing care”

Changes in nursing roles make this strategy of lumping together all nursing staff into a single measure particularly worrying.

The first nursing associates are about to enter the workforce in January, and we have been assured that they will complement and support registered nurses rather than replace them.

Meanwhile, the Nursing and Midwifery Council is being asked to rethink its requirement for people undertaking nursing degree apprenticeships to have supernumerary status.

If we are to be able to make sense of data on the relationship between nursing workforce and patient safety it is vital that the data specifies who is providing nursing care.

Without detail on the mix between registered nurses, nursing associates and apprentices, there is a risk that employers will change their skill mix to increase numbers of nursing associates relative to ‘expensive’ and difficult-to-recruit registered nurses.

The people who pay the price of such cost savings will be the patients who die due to the lack of registered nursing care.

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Readers' comments (1)

  • All absolutely spot on. I am convinced that the government have deliberately wasted the time given for the Brexit process; Teresa May was a Remainer before gaining party leadership. Despite her "Brexit means Brexit" and ostensible attempts at negotiation, we have got a rotten deal.
    Nurses have also got a rotten deal, which tells us more than all this government's words. Their actions show they want to divest themselves of the NHS, and are doing so in tiny increments via private outsourcing of services. In the meantime they make nursing less effective via introduction of cheaper substitutes, and will later say if this is where socialised medicine leads, we must privatise. Never trust a politician who robs Peter to pay Paul unless you are Paul. We unfortunately are Peter.

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