Insufficient Hospital Nurse Staffing Linked With Higher Risk of Patient Death

Insufficient staffing with RNs and nurse support staff in hospitals was associated with an increased risk of patient death, a longitudinal observational study from England suggested.

In a cohort of over 600,000 hospitalized patients, each day of low 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 low 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 Open.

While these findings aren’t novel, knowing the level of nurse staffing for every single day of a patient’s stay makes it more likely that the findings are causal, Griffiths told MedPage Today.

Of note, when low staffing was prevented with the use of temporary staff, the risk of patient death was reduced but remained elevated compared with the baseline, the authors said.

Increasing the proportion of temporary RNs by 10% was associated with a 2.3% jump in the risk of death, with no differences observed between nurses hired through external agencies (aHR 1.023, 95% CI 1.01-1.04) and temporary staff employed by the hospital, known as “bank” staff (aHR 1.02, 95% CI 1.01-1.04).

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

The authors pointed to previous studies that also suggested temporary staffing is risky for patients due to unfamiliarity with the care setting, which can disrupt care continuity.

Many hospitals in the U.S. and the U.K. rely on temporary staffing out of “necessity” but also “efficiency,” Griffiths said. While it is “worth trying to fix the staffing shortfalls by employing temporary staff … it does not return the risk to baseline,” he pointed out.

Furthermore, the similar results between bank staff and staff from external agencies showed that leveraging a hospital’s own staff doesn’t solve staffing problems, Griffiths noted, adding that this was a new finding.

While there was some evidence that having a higher proportion of senior RN staff was associated with a reduced risk of patient death (aHR 0.99, 95% CI 0.97-1.00, P=0.005), Griffiths said the inclusion of senior staff is “not a magic bullet.”

“It doesn’t really make up for the fundamental problems of not having sufficient staff,” he stressed.

Ultimately, the “only solution” to nursing shortages is to employ more RNs in conditions that are stable, safe, and familiar, he added. “We shouldn’t convince ourselves that just because we can fill gaps by employing people through a [hospital] ‘bank’ or through an agency, that we’ve solved the problem, because we haven’t.”

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

Of these admissions, 80.3% were emergencies and 65.8% were to medical specialties. The median 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 greater than 5.

Griffiths and colleagues noted that they focused on a single outcome, which was a limitation to the study, since “low staffing is known to have adverse effects on a range of outcomes for patients, quality of care, and staff.”

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