Patient safety is the driver that is threaded through all of the current Royal College of Nursing (RCN) communications, and its requests to the UK government to commence discussions concerning nursing pay.
Although it is tempting, I am not planning on writing a political opinion piece about the current debate, or the lack of one, between the RCN and the government. I do, however, feel that there is a critical need for nurses to be aware of the evidence to inform our decisions and actions in relation to nurse staffing levels and the safety of our patients.
When we consider the evidence themes that have been studied in relation to patient safety and the delivery of nursing care, we are typically concerned with nurse-driven outcomes such as harm relating to pressure damage or falls, medication errors or missed care, the ultimate patient safety measure being mortality.
So what is already known? Dall'Ora et al (2022) undertook a systematic review of studies in this area, concluding that:
‘Having more registered nurses on hospital wards is causally linked to reduced mortality.’
Dall'Ora recommended that further work with longitudinal studies would further add to the body of evidence of cause and effect.
Recently, Zaranko et al (2022) published one such longitudinal study with the objective of examining the impact of nursing team size and composition on inpatient hospital mortality. The research team specifically looked at planned versus actual staffing and the care of nearly 67 000 patients across three UK hospitals.
The results of this study demonstrated a statistically significant association between the fill-rate for registered nurses (RNs) and inpatient mortality. It should be noted that these RNs were specifically substantive hospital employees. Other findings included:
- There was no association relative to healthcare support workers (HCSWs) or agency staff
- On average, an extra 12-hour shift by an RN was associated with a reduction in the odds of a patient death of 9.6%, and an additional senior RN (in NHS pay band 7 or 8) had 2.2 times the impact of an additional band 5 RN (fill-rate for bands 7 and 8)
- Mortality increased in line with the degree of understaffing. Teams lacking 16 hours’ worth of registered nurse care in one shift saw a 23% increase in mortality, while those lacking 24 hours saw a 37% increase.
The study also concluded that RN staffing and seniority levels were associated with patient mortality. Powerfully, the lack of association for HCSWs and agency nurses indicated that they are not effective substitutes for RNs who regularly work on the ward.
Baines (2023) reported that, in responding to the findings, Lisa Elliott, the RCN's deputy director for workforce, professional practice and quality, said:
‘This research highlights the negative impact that not having enough experienced or permanent nursing staff can have on care and patient safety.’
She accused the government of relying on agency staff to fill workforce gaps rather than focusing on long-term measures to boost nurse recruitment and retention.
My reflections are that joined-up workforce planning and delivery, both nationally and locally, needs to seriously consider the powerful narrative and evidence base that is available to us. The constant use of temporary staff, the unplanned redeployment of staff on a daily basis to areas with which they are unfamiliar, and working at minimum staffing levels, is having a direct impact on patient safety. Strategic planning for the national and international pipeline of recruitment and measurable outcomes for retention needs to be an absolute patient safety priority.