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Linda Aiken: NHS policy is driving harmful variation in nurse staffing levels and diluting skill mix

The latest evidence on registered nurse numbers and patient satisfaction makes the case for safe staffing levels overwhelming, says leading nurse researcher Linda Aiken

The latest evidence on registered nurse numbers and patient satisfaction makes the case for safe staffing levels overwhelming, says leading nurse researcher Linda Aiken


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Patients’ unfavourable views of NHS hospital care are significantly associated with too few registered nurses (RNs), rather than uncaring nurses, we show in a new study published in BMJ Open.

Only 60% of 66,000 patients from 161 acute trusts surveyed by the NHS reported there were usually enough nurses to provide their care. One in ten said there were rarely enough nurses, and of these only 14% rated their care as excellent.

The likelihood of patients saying there were always enough nurses was 40% lower in hospitals where nurses cared for ten patients each, compared with hospitals where nurses cared for six patients each.

Missed care

More missed nursing care occurs when nurses are responsible for many patients each. Missed nursing care is associated with patients’ unfavourable ratings of their hospitals.

Our study found that nurses in adult medical and surgical wards in NHS hospitals cared for an average of 8.6 patients each on a day shift. However, variation between hospitals ranged from 5.6 to 11.5 patients per nurse. This wide variation in RN staffing is a major factor in unfavourable care ratings by patients.

A previous study we published in The Lancet showed that risk-adjusted hospital mortality rates for common surgeries varied substantially across hospitals, and each increase of one patient in the patient-to-nurse ratio is associated with a 7% increase in mortality.

Unsafe variation

Devolvement of autonomy to NHS trust managers to decide how to allocate resources at their hospitals, without minimum nurse staffing levels, likely contributes to more variation in nurse staffing than is safe.

The NHS is widely respected for providing equitable access to care, but there is evidence of much variation in nurse staffing – and this is associated with significant variation in quality of care, patient satisfaction and mortality. This constitutes a clarion call to require hospitals to meet safe nurse staffing levels.

Our study shows that patients’ confidence in doctors and nurses is equally important to their satisfaction with hospital care. Confidence in nurses was largely a function of how many nurses were at the bedside.

Quality and value

Between 2010 and 2015 the number of consultants employed by the NHS increased more than 20% while the number of RNs employed increased by only 1%. More balanced investment in the workforce would have the potential to yield a better return in quality and value.

Other recent NHS nursing policies go against the evidence about what affects good patient outcomes. The addition of new nursing associates with less education than RNs erodes the hospital nursing skill mix. Each 10% decline in the proportion of hospital staff at RN level is associated with a 12% increase in mortality.

Promoting apprentice training for professional nurses rather than university science-based bachelor’s degree education is not in the public interest. Every 10% increase in the proportion of RNs with bachelor’s degrees is associated with a 7% decline in mortality.

Evidence-based policies are essential, especially when resources are scarce.


Linda Aiken is professor and director, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, US 

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