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The University of Southampton

Lack of qualified nursing associated with increased mortality in hospital

Published: 5 December 2018
The study highlights the possible consequences of reductions in qualified nurse staffing

Lower levels of Registered Nurses (RN) and a greater use of nursing assistants are associated with an increased risk of death during an admission to hospital, according to a new study led by researchers at the University of Southampton.

The findings in a new paper, published in BMJ Quality and Safety, highlight the possible consequences of reductions in qualified nurse staffing, experienced in recent years in the UK, whilst demonstrating that policies encouraging the increased use of nursing assistants to compensate for shortages of RNs may be putting lives at risk.

Lead author, Professor Peter Griffiths, Chair of Health Services Research and Head of the Health Work Research Group at the University of Southampton, emphasises that this study – the first to look at the effects of nursing assistants in the workforce - and its findings will have significant implications, particularly for hospitals that consider adding assistants as a means of making up for RN shortages. 

“At a time when the NHS is facing increasing difficulties in recruiting and retaining staff, this research reveals the potential consequences of shortages of registered nurses in terms of the negative impact on patient safety,” says Professor Griffiths, “Assistant staff are an important part of the team but adding more of them is not the solution.”

The study, Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal observational study, involved the Universities of Southampton, Portsmouth and York and the National Institute for Health Research (NIHR) which funded the research. The team examined three years of hospital data from 32 wards across a large English hospital, covering almost 140,000 patients who were admitted to general hospital wards between 1 April 2012 and 31 March 2015.

The findings show that for every hour less of nursing care per patient over the first five days of a hospital stay, the risk of a patient dying was increased by 3%. High numbers of admissions per nurse also increased the risk of death significantly, whilst adding nursing assistants above current levels seemed to increase rather than decrease the risk.

This is an observational study, which directly can’t prove cause. But researchers say this builds on findings from a number of other studies and excludes many other possible explanations making cause and effect more likely.

“Nursing care assistants do have an important part to play in maintaining the safety of hospital wards but they cannot act as substitutes for registered nurses,” Professor Griffiths continues. “The risk of death went up when nursing assistant staffing was low but it also increased when it went above the typical level for a ward. We are not sure why that happened but we think it is because there are not enough trained nurses to supervise the assistants and assistants don’t have the skills to recognise and act when a patient starts to deteriorate.”

“This study shows us how important it is to have properly qualified nurses working on wards and registered nurses and care assistants should not be treated as equivalent,” says Consultant Physician and co-investigator, Dr Paul Schmidt. “We need to improve the supply of registered nurses because RN shortages can cause great harm to patients and we can’t fix it by increasing the numbers of lesser trained nursing staff in the workforce.”

This study is the latest in a series of studies and commissioned reports led by researchers at the University of Southampton on uneven quality of care in NHS hospitals in England pointing to the need for increasing the number of funded positions in NHS hospitals for highly qualified professional nurses. 


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