Higher nurse-to-patient ratio decreases risk of death

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Student nurses from City University marching against the abolition of nursing bursaries which will deter recruitment
Student nurses from City University marching against the abolition of nursing bursaries which will deter recruitment

A HIGHER nurse-to-patient ratio is linked to a reduced risk of inpatient death, finds a study of staffing levels in NHS hospitals, published in the online journal BMJ Open.

In trusts where registered (professionally trained) nurses had six or fewer patients to care for, the death rate was 20 per cent lower than in those where they had more than 10.

Policies geared towards substituting registered nurses with healthcare support workers (healthcare assistants and nursing auxiliaries) should at the very least be reviewed, conclude the researchers.

Previous research suggests that the nurse to patient ratio has some bearing on outcomes, but few studies have taken account of the impact of other members of medical staff.

They therefore included two measures over two years (2009-11) in their analysis: the number of beds per registered nurse, doctor, and healthcare support worker in 137 acute care trusts; and the number of patients per ward nurse, drawn from a survey of just under 3000 registered nurses in a nationally representative sample of 31 of these trusts (covering 46 hospitals and 401 wards).

They also calculated the predicted number of deaths for medical and surgical inpatients, taking account of influential factors, such as age, other underlying conditions, and number of emergency admissions during the previous 12 months.

The registered nurse headcount varied by as much as a factor of four between those at the top and bottom of the staffing scale. Even after taking account of all nursing staff, this variation only dropped to a threefold difference between those with the highest and lowest nurse headcounts.

Among patients admitted to medical wards, higher death rates were associated with higher numbers of occupied beds for each registered nurse and for each doctor employed by the trust.

By contrast, higher numbers of healthcare support workers were associated with higher rates of inpatient death. When all staff groups were included in the statistical analysis of all 137 trusts, the associations remained significant only for doctors and healthcare support workers.

The death rate was 20 per cent lower in those trusts where each registered nurse cared for an average of six or fewer medical inpatients than in trusts where each registered nurse cared for 10 or more. These associations remained significant after further statistical analysis.

The results on surgical wards were similar, with higher registered nurse to patient ratios associated with a 17 per cent lower inpatient death rate. This is an observational study, so no firm conclusions can be drawn about cause and effect, added to which the findings on nurse to patient ratios are based on only 31 trusts.

‘This (study) does not, in itself, provide a robust basis to identify safe staffing thresholds,’ they say. However, given the overall strength of evidence for an association, it does seem feasible to identify staffing levels where risk to patients is likely to be increased,’ they suggest.

Economic pressures and the ageing profile of the nursing workforce internationally all point to a potential future with fewer registered nurses, they warn. Substituting them for less well trained staff may be unwise, they say.

‘When determining the safety of nurse staffing on hospital wards, the level of registered nurse staffing is crucial, and there is no evidence to suggest that higher levels of healthcare support worker staffing have a role in reducing mortality rates,’ they write.

‘Current policies geared towards substituting (these) workers for registered nurses should be reviewed in the light of this evidence,’ they conclude. Meanwhile, the country’s most vulnerable children are being put at risk by diminishing safeguarding services, the Royal College of Nursing (RCN) has warned.

An RCN survey of Designated Nurses for Safeguarding Children, published yesterday, has found that only two fifths are able to focus on protecting children and young people. While there are currently over 50,000 children identified as needing protection from abuse in the UK, the NSPCC predicts the real figure could be eight times higher.

Designated Nurses for Safeguarding Children play a crucial strategic role in protecting children by ensuring all health services have access to the expertise, training and resources to identify children at risk and provide help as soon as possible.

However, more than 30 per cent of those surveyed said safeguarding formed less than half their role, and eight per cent said it made up just a tenth. 27 per cent had managerial responsibilities while almost 30 per cent had to spend time on commissioning tasks unrelated to their safeguarding duties.

Nearly a third of those surveyed said they had no safeguarding team to provide support or assistance, while one in ten said they received no supervision. In a position statement also published yesterday, the RCN is calling for health services to recognise the value of Designated Nurses for Safeguarding Children and to ensure they have the capacity and resources to fulfil their vital role.

Fiona Smith, Professional Lead for Children and Young People’s Nursing at the RCN, said: ‘Preventing child abuse and neglect should be one of the country’s utmost priorities. Designated Nurses for Safeguarding Children are an absolutely crucial part of this process.

‘This role is far too important to be watered down. These highly skilled and expert nurses are responsible for ensuring health care services have all they need to protect vulnerable children, so lessening their role will have a widespread detrimental impact. 

‘Each and every Designated Nurse needs the time and resources to fulfil their role to the best of their ability. By failing to achieve this, more and more children are left vulnerable to abuse and neglect – and that is inexcusable.’

On another issue, in response to claims made by Jim Mackey, whose job title is ‘Chief Executive of NHS Improvement’, the RCN stressed it is wrong to blame nurses for financial pressures in the NHS when the government created the staffing crisis by cutting nurse training places.

In a statement reported in Murdoch’s Times newspaper on Monday, Mackey suggested nursing staff are exploiting the system to push up agency fees. RCN Head of Policy and International Howard Catton responded: ‘Hardworking staff are not the problem and focusing on them is the wrong approach. It sends the wrong message. There is a system-wide failure of planning and a continued unwillingness to properly value staff.’

A recent report from the National Audit Office showed planning for the supply of health care workers in England is fragmented and needs improvement. The RCN stressed it is this that must be addressed. Nurses have seen their pay fall by 10 per cent in real terms over the last five years,’ added Howard.

‘Staff are overworked, underpaid and are working in hugely pressurised environments.

‘Until the NHS truly values its permanent nursing staff, pays them fairly, and offers them the flexible working conditions their family lives require, it will remain unsurprising that some nurses decide to work for agencies.’

A report on managing the supply of clinical staff in England, published last week, called on the Department of Health, Health Education England and NHS Improvement to provide greater national leadership to help trusts address shortfalls. In 2014 there was a staffing shortfall of nearly six per cent, or 50,000 clinical staff, in England.

The RCN’s Catton said: ‘The responsibility for workforce supply is ultimately a political one. We have been concerned for some time that the bottom-up predictions and assessments for demands for staff are overwhelmingly influenced by financial considerations and it is for that reason you need stronger top-down control.’