Patients ‘21% more likely to die in hospitals with less-qualified nursing staff’

Patients are a fifth more likely to die in hospitals where nurses are replaced with less-qualified staff, new research suggests.

The study found patients were more likely to die and suffered poorer quality of care when the proportion of qualified nurses is diluted with lower-skilled nursing assistants.

A leading expert behind the research warned that the Government’s new policy of bringing in nursing associates to do some of the work of registered nurses was a “risky experiment”.

Ministers have announced 2,000 nursing associate roles across England, with the first 1,000 due to start training at 11 test sites from next month.

They will learn to take on some of the jobs of nurses, including administering controlled drugs and carrying out invasive procedures.

But the new research warns that diluting the skills mix – especially in England, which already has one of the lowest ratios of qualified nurses to other staff – puts lives at risk.

The research, published in the journal BMJ Quality & Safety, included data from 32 NHS hospital trusts in England, as well as hospitals in Belgium, Finland, Ireland, Spain and Switzerland.

For every 25 patients, substituting just one qualified nurse for a lower-qualified member of staff was associated with a 21% rise in the odds of dying.

This was in hospitals with average staffing, with 66% qualified nurses among the total nursing staff.

In the NHS in England, the average is just 57% – one of the lowest in Europe – and varies from 79% to 47% depending on the hospital.

The research found that patients looked after in hospitals with a higher proportion of nurses were less likely to give poor ratings about their care, and suffered fewer bedsores, falls, and urinary infections – often markers of poor care.

Nurses in these hospitals reported fewer issues with patient safety, had less burnout and job dissatisfaction and were less likely to report an “inadequate safety culture”.

One of the researchers, Professor Peter Griffiths, from the University of Southampton, urged ministers to take on board the findings from the study.

He said: “This is really important because in the NHS, for quite a long time, we’ve struggled to recruit enough NHS nurses, but we’ve consistently trained fewer than we need.

“Policy has proceeded with the view that we could put other roles into the workforce to make up the shortfall. But this study – and other studies of this type – consistently raise questions about whether this is the case.

“Fewer registered nurses in the workforce – and more reliance on lesser qualified staff – is associated with an increased risk of death.

“I think this certainly shows that what’s currently being proposed needs to be regarded as a risky experiment and needs to be closely evaluated for the impact on patient outcomes.”

The study noted that, across Europe, hospital nurse staffing “is a frequent target for budget reductions”.

It said: “Policymakers are suggesting the introduction of lower skilled and less educated nurse substitutes like ‘nursing associates’… our results suggest caution is warranted.”

The research involved survey responses for just over 13,000 nurses in 243 hospitals and almost 19,000 patients in 182 of these hospitals.

Experts also looked at discharge data in 188 hospitals for more than 275,500 patients who had undergone surgery. They also examined staffing ratios on a shift.

The results found that for every 10% rise in the proportion of professionally qualified nurses, there was an 11% fall in the odds of a patient dying after surgery, a 10% fall in the odds of patient dissatisfaction, and an 11% fall in the odds of reporting poor quality care.

The researchers stressed that the study was observational and could not prove cause and effect.

But they said: “Findings from this large and unique study of nursing skill mix in European hospitals suggest that caution should be taken in implementing policies to reduce hospital nursing skill mix, because the consequences can be life-threatening for patients.”

They said diluting hospital nurse skill mix was “not in the public interest”.

Last week, Janet Davies, chief executive of the Royal College of Nursing (RCN), said allowing unregistered nursing associates to give drugs to patients risks safety and was “ridiculous”.

Unison head of health, Christina McAnea, said: “The research confirms that safe staffing levels are crucial, and that nurse associates are no substitute for registered nurses.

“The Government must tackle the shortage of nurses head on rather than look for cheap alternatives.”

Ms Davies said: “This research reinforces the stark fact that for patient care to be safe, and high quality, you need the right number of registered nurses. Substituting registered nurses with support staff quite simply puts patient care and patients’ lives at risk.

“It’s vital that this is not ignored as the new nursing associate role is developed. Support staff are crucial in delivering patient care and the NHS could not operate without them, but they cannot and must not become a substitute for registered nurses.

“The registered nurse is educated to degree level and has a wide range of clinical experience. This means that they are adept at spotting signs of deterioration or serious complications and can make decisions and act on them in complex and unpredictable circumstances.

“Staff and patients can see the effects when staffing levels become diluted – in some instances the effects can be catastrophic.”

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