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Lower staff levels of registered nurses driving up hospital mortality rates

Care left undone by nurses due to a lack of time is the “missing link” in understanding variation in mortality rates in hospitals, a new study has found.

Conducted by Dr Jane Ball at the University of Southampton, the research shows that hospitals with lower registered nursing (RN) staff had a higher risk of patient death as staff did not have the time to deliver complete nursing care.

Each 10% increase in the amount of care left undone was found to be linked to a 16% increase in the likelihood of a patient dying following common surgery, Dr Ball discovered.

The findings were taken from investigations of the RN4CAST study of nurse staffing at hospitals in nine European countries, which included 31 NHS acute trusts in England.

Previous analysis of the survey showed that lower nurse staffing levels are associated with higher mortality. Missed nursing care was defined through a nurse survey, and includes activities like patient surveillance, administering medicine on time, adequate documentation, comforting patients and pain management.

“For years we have known that there is a relationship between nurse staffing levels and hospital variation in mortality rates but we have not had a good explanation as to how or why,” Dr Ball said.

“These results give the clearest indication yet that RN staffing levels are not just associated with patient mortality, but that the relationship may be causal.

“If there are not enough registered nurses on hospital wards, necessary care is left undone, and people’s lives are put at risk.”

The study also looked into nurse qualification, and confirmed that hospitals with a higher number of registered nurses trained at degree level had lower patient mortality rates.

Professor Peter Griffiths, chair of Health Services Research at the University of Southampton, added: “This study reinforces the importance of registered nurses who are trained to a degree level. It is more evidence that shows that you cannot substitute fully qualified RNs with less qualified staff, without taking a risk with patient safety.

“It is the number of RNs on duty that is key to ensuring complete care and minimising the risk of patients dying.” 

And co-author of the report Luk Bruyneel, from KU Leuven in Belgium, commented: “These findings have implications for healthcare managers and policymakers.

“Monitoring missed care may offer a more responsive and sensitive early-warning system for hospitals to detect problems before patients die. More work needs to be done worldwide to ensure we utilise this data for the benefit of patients.”

RCN: patients pay highest price when gov gets nurses ‘on the cheap’

The Royal College of Nursing also said that the findings reinforced warnings that the organisation had been voicing for a while, and highlighted how the quality of nurses in wards had a direct impact on patient safety.

“Despite years of warnings, hospitals across the country do not have enough nurses,” Janet Davies, the RCN’s chief executive and general secretary explained. “This research puts beyond doubt that patients pay the very highest price when the government permits nursing on the cheap.

“As the nurse shortage bites, hospitals are filling wards with unregistered healthcare assistants in a bid to cope, especially at night,” she argued. “Ministers cannot ignore further evidence that the lack of registered nurses leads to people left in pain for longer and a higher risk of not recovering at all.

Davies also stated that as pressure in the NHS was mounting, nurses were pulled in every direction and important things were inevitably being missed.

“Patients stand a better chance of recovery when there are more degree-trained nurses on the wards,” she continued. “The government must redouble its efforts to train and recruit more nurses and stop haemorrhaging experienced professionals who feel burnt out and undervalued.

“In the forthcoming Budget, the chancellor must scrap the public sector pay cap that stands in the way.”

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