title: Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  Cross-sectional analysis combining nurse survey data with discharge abstracts.
  
  
  METHODS
  Nurses (N=3984) and general, orthopaedic, and vascular surgery patients (N=118752) 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.
authors.affiliation: Florence Nightingale School of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK. anne_marie.rafferty@kcl.ac.uk
authors.forename: Anne Marie
authors.initials: AM
authors.lastname: Rafferty
authors.forename: Sean P
authors.initials: SP
authors.lastname: Clarke
authors.forename: James
authors.initials: J
authors.lastname: Coles
authors.forename: Jane
authors.initials: J
authors.lastname: Ball
authors.forename: Philip
authors.initials: P
authors.lastname: James
authors.forename: Martin
authors.initials: M
authors.lastname: McKee
authors.forename: Linda H
authors.initials: LH
authors.lastname: Aiken
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D002055:Burnout, Professional / Q000453:epidemiology / Q000523:psychology; D003430:Cross-Sectional Studies; D004739:England / Q000453:epidemiology; D005260:Female; D006742:Hospital Bed Capacity / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007588:Job Satisfaction; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015401:Nursing Administration Research; D015404:Nursing Methodology Research; D009741:Nursing Staff, Hospital / Q000523:psychology / Q000600:supply & distribution; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; D011787:Quality of Health Care; D011795:Surveys and Questionnaires; D016526:Workload