Death rate rises if nurse/patient ratio is higher than one to six

Major study also analysed the mortality rates when nurses are substituted by healthcare support workers


Hospitals with higher levels of nurses per patient have lower death rates, according to a study led by the University of Southampton and King’s College London.

The research found that in trusts where nurses had six or fewer patients to care for, the death rates for patients with medical conditions was 20% lower than those where they cared for ten or more patients.

The study, which took place between 2009 and 2011, analysed the number of beds per nurse, doctor, and healthcare support worker (HCSW) in 137 acute care trusts. It also considered the number of patients per nurse, surveying almost 3,000 registered nurses at 31 of the trusts.

The study highlighted an 8–13% increase in the rates of mortality for each additional bed per doctor. And larger numbers of HCSWs were associated with higher rates of inpatient death.

Researchers have called for an urgent review of policies of substituting nurses with HCSWs.

University of Southampton chair of health services research Peter Griffiths told Nursing Standard: ‘HCSWs are often taking the vital signs – essential monitoring – but it is not always clear they have the skills and knowledge to know what to do with the information they are gathering or that they are always reporting it to a nurse.’

Anne Marie Rafferty, professor of nursing policy at King’s College, London, said the study ‘flags the need for caution and the dangers of simply substituting HCSWs for qualified nursing staff’.  

Safe Staffing Alliance chair Susan Osborne said evidence from abroad and decades of previous research showed that the best nurse-to-patient ratio is one to four or one to five with additional support from HCSWs and a nurse in charge of the ward.

She said: ‘There is comprehensive research saying that we have too many HCSWs. But no one is listening.

‘The real issue is that we have a very low number of nurses. The Care Quality Commission flag this when they do their inspections but there is no joined-up thinking and the problem is getting worse.’

RCN head of policy Howard Catton told Nursing Standard: ‘Money would be best spent on growing the numbers of nurses. There is a risk of developing more HCSWs or nursing associates that cash-strapped providers of healthcare are tempted to substitute for nurses to meet cost constraints.’

Nurse Jane Ball, principal research fellow at the National Institute for Health Research at the Collaborations for Leadership in Applied Health Research and Care (Wessex), adds: ‘When determining the safety of nurse staffing on hospital wards, the level of registered nurse staffing is crucial; hospitals with higher levels of healthcare support workers have higher mortality rates.

‘Patients should not be asked to pay the price of receiving care from a less skilled and less educated member of staff, just to make up for the failure of the system to ensure there is enough registered nurses. Staffing decisions need to be made on the basis of patient safety, not on the basis of finance. Current policies geared towards substituting these workers for nurses should be reviewed.’

A Department of Health spokesperson said: ‘We expect all parts of the NHS to make sure they have the right staff, in the right place, at the right time, to provide safe care.’

New regulator NHS Improvement is due to publish guidance on safe staffing later this year.

Read more about the study here

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