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Greater death risk linked to replacing qualified nurses with less skilled support workers



Replacing professionally qualified nurses with lower skilled nursing assistants has been linked to a heightened risk of patient death, as well as other indicators of poor quality care, a study in BMJ Quality Safety has revealed.

Replacing professionally qualified nurses with lower skilled nursing assistants has been linked to a heightened risk of patient death, as well as other indicators of poor quality care, a study in BMJ Quality & Safety has revealed.

It was found that for every 25 patients, just one professional nurse substitution was associated with a 21% rise in the odds of dying in hospital with average nurse staffing levels and skill mix.

The study, the first of its kind, compared nursing skill mix in over 200 hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland.

It concluded that “diluting” the hospital nurse skill mix by adding lower skilled assistants or reducing the number of nurses “is not in the public interest.”

In England, where the nursing associate role has just been introduced, the nursing skill mix varies from 79% of professional nurses to 47%, with an average of 57%—one of the lowest in Europe. The average across Europe is 66%.

Janet Davies, RCN chief executive and general secretary, 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 study analysed the association between nursing skill mix and the risk of patient death, patients’ views of their care, and other quality of care indicators, such as the prevalence of falls and bedsores, in acute care hospitals.

The findings are based on survey responses from just over 13,000 nurses in 243 hospitals and nearly 19,000 patients in 182 of these hospitals, as well as discharge data for more than 275,500 patients who had undergone a surgical procedure in 188 of the hospitals.

Around one in five nurses rated the care on their unit as poor or fair, and around a third said their hospital had a poor safety culture.

Nearly a third showed signs of burnout and a similar proportion were dissatisfied with their job. Around half the patients surveyed gave their hospitals low ratings.

The final analysis showed that a higher proportion of professionally qualified nurses was associated with a significantly lower risk of death, higher levels of patient satisfaction, and fewer reported indicators of poor quality care, such as bedsores, falls, and urinary infections.

Additionally, in hospitals with a higher proportion of professionally qualified nurses, these nurses were less likely to experience burnout or to be dissatisfied with their jobs.

The researchers 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.”

And they conclude: “Our study adds new and important evidence that diluting hospital nurse skill mix by adding lower skilled nurse assistants and/or reducing professional nurses is not in the public interest.”