Inadequate nursing staff in hospitals increases the risk of death for patients

Inadequate staffing of hospitals with nurses and nursing assistants is associated with an increased risk of death for patients, as a longitudinal study from England suggests.

In a cohort of over 600,000 hospitalized patients, each day of under-RN staffing was associated with an increased risk of death within 30 days of admission (adjusted HR 1.08, 95% CI 1.07-1.09), as was each day of under-nurse support staffing (aHR 1.07, 95% CI 1.06-1.08), reported Peter Griffiths, RN, PhD, of the University of Southampton, and co-authors in JAMA network opened.

Although these findings are not new, knowing the nursing staff for each day of a patient's stay makes it more likely that the findings are causal, Griffiths said MedPage Today.

It is noteworthy that when understaffing was avoided by using temporary staff, the risk of death among patients decreased but still remained elevated compared to baseline, the authors say.

A 10% increase in the proportion of temporary nurses was associated with a 2.3% increase in the risk of death. There were no differences between nurses recruited through external agencies (aHR 1.023, 95% CI 1.01-1.04) and temporary workers employed by the hospital, the so-called “bank staff” (aHR 1.02, 95% CI 1.01-1.04).

In addition, a 10% increase in the proportion of agency caregiver support was associated with a 4% increase in the risk of death (aHR 1.04, 95% CI 1.02–1.06).

The authors referred to previous studies that also suggested that employing temporary workers posed risks to patients because they were unfamiliar with the care environment and could disrupt continuity of care.

Many hospitals in the US and UK rely on temporary workers out of “necessity” but also for “efficiency reasons,” Griffiths said. While it is “worth trying to address staff shortages by hiring temporary workers … it will not bring the risk back to baseline levels,” he stressed.

In addition, the similar results between bank employees and employees of outside agencies show that using a hospital's own staff does not solve staffing problems, Griffiths noted, adding that this is a new finding.

There was some evidence that a higher proportion of senior nurses was associated with a lower risk of patient death (aHR 0.99, 95% CI 0.97-1.00, P=0.005), Griffiths said that involving senior managers was “not a panacea”.

“This does not really compensate for the fundamental problems of staff shortages,” he stressed.

Ultimately, the “only solution” to the nursing shortage is to employ more nurses in stable, safe and familiar conditions, he added. “We should not tell ourselves that just because we can fill gaps by moving people over a long period of time, [hospital] 'Bank' or through an agency, to believe that we have solved the problem, because we have not.”

For this study, the authors included 626,313 admissions (51% aged 65 years and over, 55.6% women) from 185 wards in four acute hospitals in England from April 2015 to March 2020. Patients were eligible to participate if they had an overnight stay and nursing staff were available on adult inpatient wards.

Of these admissions, 80.3% were emergency and 65.8% were specialist admissions. The mean length of hospital stay was 3.63 days. The majority of admitted patients had at least one comorbidity and 44.6% had a Charlson Comorbidity Index score of over 5.

Griffiths and colleagues noted that they focused on a single outcome, which was a limitation of the study because “understaffing is known to have negative effects on a range of patient, quality of care and staff outcomes.”