Outcomes of variation in hospital nurse staffing in English hospitals: Cross-sectional analysis of survey data and discharge records

Abstract

Context-Despite growing evidence in the US, little evidence has been available to evaluate whether internationally, hospitals in which nurses care for fewer patients have better outcomes in terms of patient survival and nurse retention.Objectives-To examine the effects of hospital-wide nurse staffing levels (patient-to-nurse ratios) on patient mortality, failure to rescue (mortality risk for patients with complicated stays) and nurse job dissatisfaction, burnout and nurse-rated quality of care.Design and setting-Cross-sectional analysis combining nurse survey data with discharge abstracts.Participants-Nurses (N = 3984) and general, orthopaedic, and vascular surgery patients (N = 118 752) in 30 English acute trusts.Results-Patients and nurses in the quartile of hospitals with the most favourable staffing levels (the lowest patient-to-nurse ratios) had consistently better outcomes than those in hospitals with less favourable staffing. Patients in the hospitals with the highest patient to nurse ratios had 26% higher mortality (95% CI: 12-49%); the nurses in those hospitals were approximately twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals.Conclusions-Nurse staffing levels in NHS hospitals appear to have the same impact on patient outcomes and factors influencing nurse retention as have been found in the USA. Outcomes of variation in hospital nurse staffing in English hospitalsThe impact of nurse staffing on patient outcomes has been controversial in the US and as contentious in the UK. A 2001 Audit Commission report on ward staffing in National Health Service (NHS) hospitals noted considerable variation across trusts in expenditures on nurse staffing but was not able to determine whether those differences were associated with variation in patient outcomes (Audit Commission, 2001). The Commission concluded, "Unless and until trusts that spend more [on staffing] can demonstrate a clear link with the quality of care that is delivered, movement towards a more even allocation of resources seems reasonable both for patients and staff." (1, p. 15). The Healthcare Commission released a report in June 2005 suggesting that patients were more satisfied in hospitals with more qualified nurses but emphasized again the lack of evidence linking staffing to patient outcomes and the need for research to guide decision-making in this area (Healthcare Commission, 2005).The Audit Commission's report coincided with the publication of the first results from the five-country International Hospital Outcomes Study. The International Hospital Outcomes Study, involving seven interdisciplinary research teams in five countries (US, Canada, England, Scotland and Germany), examined the extent to which the relationships between nurse staffing, the quality of the nurse work environment, and patient and nurse outcomes are similar across countries with well-resourced health care systems (Aiken et al., 2002a, b). It was seen that...

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