title: Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study.
abstract: OBJECTIVE
  To examine associations between mortality and registered nurse (RN) staffing in English hospital trusts taking account of medical and healthcare support worker (HCSW) staffing.
  
  
  METHODS
  Secondary care provided in acute hospital National Health Service (NHS) trusts in England.
  
  
  METHODS
  Two data sets are examined: Administrative data from 137 NHS acute hospital trusts (staffing measured as beds per staff member). A cross-sectional survey of 2917 registered nurses in a subsample of 31 trusts (measured patients per ward nurse).
  
  
  METHODS
  Risk-adjusted mortality rates for adult patients (administrative data).
  
  
  RESULTS
  For medical admissions, higher mortality was associated with more occupied beds per RN (RR 1.22, 95% CI 1.04 to 1.43, p=0.02) and per doctor (RR 1.10, 95% CI 1.05 to 1.15, p <0.01) employed by the trust whereas, lower HCSW staffing was associated with lower mortality (RR 0.95, 95% CI 0.91 to 1.00, p=0.04). In multivariable models the relationship was statistically significant for doctors (RR 1.08, 95% CI 1.02 to 1.15, p=0.02) and HCSWs (RR 0.93, 95% CI 0.89 to 0.98, p<01) but not RNs (RR 1.14, 95% CI 0.95 to 1.38, p=0.17). Trusts with an average of ≤ 6 patients per RN in medical wards had a 20% lower mortality rate compared to trusts with >10 patients per nurse (RR 0.80, 95% CI 0.76 to 0.85, p<0.01). The relationship remained significant in the multivariable model (RR 0.89, 95% CI 0.83 to 0.95, p<0.01). Results for surgical wards/admissions followed a similar pattern but with fewer significant results.
  
  
  CONCLUSIONS
  Ward-based RN staffing is significantly associated with reduced mortality for medical patients. There is little evidence for beneficial associations with HCSW staffing. Higher doctor staffing levels is associated with reduced mortality. The estimated association between RN staffing and mortality changes when medical and HCSW staffing is considered and depending on whether ward or trust wide staffing levels are considered.
authors: National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK University of Southampton, Southampton, UK.
authors: Peter
authors: P
authors: Griffiths
authors: National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK Karolinska Institutet, Stockholm, Sweden.
authors: Jane
authors: J
authors: Ball
authors: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
authors: Trevor
authors: T
authors: Murrells
authors: Department of Population Health, New York University School of Medicine, New York, New York, USA.
authors: Simon
authors: S
authors: Jones
authors: Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
authors: Anne Marie
authors: AM
authors: Rafferty
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D004739:England; D017052:Hospital Mortality; D006761:Hospitals; D006801:Humans; D008505:Medical Staff, Hospital / Q000600:supply & distribution; D009726:Nurses; D009741:Nursing Staff, Hospital / Q000600:supply & distribution*; D010561:Personnel Staffing and Scheduling; D010564:Personnel, Hospital / Q000600:supply & distribution*; D000078329:Workforce