Griffiths Peter, Saville Christina, Ball Jane, Culliford David, Jones Jeremy, Lambert Francesca, Meredith Paul, Rubbo Bruna, Turner Lesley, Dall'Ora Chiara
Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.
Clinical Outcomes Research Group, Portsmouth Hospitals University Trust, NHS, Portsmouth, UK.
Health Soc Care Deliv Res. 2025 Jul;13(25):1-107. doi: 10.3310/ZBAR9152.
The National Health Service faces significant challenges in recruiting and retaining registered nurses. Recruiting unregistered staff is often adopted as a solution to the registered nurse shortage, but recent research found lower registered nurse staffing levels increase hospital mortality with no evidence that higher levels of assistant staff reduced risk.
To estimate the consequences, costs and cost-effectiveness of variation in the size and composition of the staff on acute hospital wards in England. To determine if results are likely to be sensitive to staff groups such as doctors and therapists, who are not on ward rosters, associations between staffing and outcomes for multiple staff groups, including medical, are explored at hospital level.
A national cross-sectional panel study and a patient-level longitudinal observational study using routine data.
All English acute hospital Trusts and a subsample of four Trusts for the patient-level study.
Naturally occurring variation in the size and composition of the workforce.
Patients experiencing a hospital admission with an overnight stay and nursing staff providing care on inpatient wards.
Death, patient and staff experience, length of stay, re-admission, adverse events, incidents (Datix), staff sickness, costs and quality-adjusted life-years.
Publicly available records of hospital activity, staffing and outcomes (cross-sectional study) and hospital administrative systems (longitudinal study).
In the cross-sectional study, lower staffing levels from doctors and allied health professionals were associated with increased risk of death. Higher nurse staffing levels were associated with better patient experience and staff well-being. In the longitudinal study, for adult inpatients, exposure to days with lower-than-expected registered nurses or nursing assistant staff was associated with increased hazard of death (adjusted hazard ratio 1.08/1.07, 95% confidence interval 1.07 to 1.09/1.06 to 1.08) and longer hospital stays. Low registered nurse staffing was also associated with increased hazard of re-admission (adjusted hazard ratio 1.01, 95% confidence interval 1.01 to 1.02). Eliminating low staffing cost £2778 per quality-adjusted life-years gained. Avoidance of registered nurse understaffing gave more benefits and was more cost-effective for highly acute patients. Although high bank or agency staffing was associated with increased hazard of death, avoiding low staffing using temporary staff still reduced mortality but was more costly and less effective than using permanent staff. If costs of avoided hospital stays are included, avoiding low staffing generates a net cost saving. Exploration of thresholds for low staffing indicated a greater beneficial effect from registered nurse staffing higher than current norms.
This is an observational study. Causal inferences cannot be made from these results in isolation. Quality-adjusted life-years gains were estimated, although conclusions are not sensitive to assumptions or discount rates. We used current ward norms as reference for low staffing.
Our results show the adverse effects of low nurse staffing but also show that medical and allied health professional staffing are important considerations for patient safety. Eliminating low registered nurse staffing gave more benefits than eliminating assistant staffing.
Research is needed to validate methods to determine nurse staffing requirements, and the interaction between registered nurse and assistant staffing needs further exploration.
This study is registered as Current Controlled Trials ClinicalTrials.gov NCT04374812.
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128056) and is published in full in ; Vol. 13, No. 25. See the NIHR Funding and Awards website for further award information.
英国国家医疗服务体系在招聘和留住注册护士方面面临重大挑战。招聘未注册员工常被用作解决注册护士短缺问题的办法，但最近的研究发现，较低的注册护士人员配备水平会增加医院死亡率，且没有证据表明增加辅助人员能降低风险。
评估英格兰急性医院病房工作人员规模和构成变化的后果、成本及成本效益。确定结果是否可能对未列入病房排班的医生和治疗师等工作人员群体敏感，在医院层面探讨多个工作人员群体（包括医疗人员）的人员配备与结果之间的关联。
一项全国性横断面小组研究和一项使用常规数据的患者层面纵向观察性研究。
所有英格兰急性医院信托机构以及用于患者层面研究的四个信托机构的子样本。
劳动力规模和构成的自然变化。
住院过夜的患者以及在住院病房提供护理的护理人员。
死亡、患者和工作人员体验、住院时间、再入院、不良事件、事件（Datix）、工作人员病假、成本和质量调整生命年。
公开可用的医院活动、人员配备和结果记录（横断面研究）以及医院管理系统（纵向研究）。
在横断面研究中，医生和专职医疗专业人员的较低人员配备水平与死亡风险增加相关。较高的护士人员配备水平与更好的患者体验和工作人员幸福感相关。在纵向研究中，对于成年住院患者，暴露于注册护士或护理助理人员低于预期的天数与死亡风险增加（调整后的风险比为1.08/1.07，95%置信区间为1.07至1.09/1.06至1.08）和更长的住院时间相关。低注册护士人员配备也与再入院风险增加相关（调整后的风险比为1.01，95%置信区间为1.01至1.02）。消除低人员配备每获得一个质量调整生命年成本为2778英镑。避免注册护士人员不足对高度急症患者带来更多益处且更具成本效益。尽管高银行或代理人员配备与死亡风险增加相关，但使用临时人员避免低人员配备仍可降低死亡率，但比使用永久人员成本更高且效果更差。如果将避免的住院成本计算在内，避免低人员配备可产生净成本节约。对低人员配备阈值的探索表明，高于当前标准的注册护士人员配备具有更大的有益效果。
这是一项观察性研究。不能仅凭这些结果进行因果推断。尽管结论对假设或贴现率不敏感，但仍估计了质量调整生命年的收益。我们将当前病房标准用作低人员配备的参考。
我们的结果显示了低护士人员配备的不利影响，但也表明医疗和专职医疗专业人员的人员配备是患者安全的重要考虑因素。消除低注册护士人员配备比消除助理人员配备带来更多益处。
需要进行研究以验证确定护士人员配备要求的方法，注册护士与助理人员配备之间的相互作用需要进一步探索。
本研究在ClinicalTrials.gov（NCT04374812）注册为当前对照试验。
本奖项由国家卫生与保健研究机构（NIHR）卫生与社会保健交付研究计划资助（NIHR奖项编号：NIHR128056），并全文发表于《……》；第13卷，第25期。有关更多奖项信息，请参阅NIHR资金与奖项网站。
