Public Release: 

Patients' unfavorable views of hospital care strongly linked to nurse numbers

Increasing the headcount may boost satisfaction with quality of care, say researchers

BMJ

Patients' unfavourable views of hospital care in England are strongly linked to insufficient numbers of nurses on duty, rather than uncaring staff, indicates observational research published in the online journal BMJ Open.

Increasing the registered nurse headcount may boost satisfaction with the quality of care, conclude the researchers, who base their findings on national survey data from patients and nurses.

The 2010 NHS Survey of Inpatients gathered information from over 66,000 patients who had been discharged from 161 acute and specialist NHS Trusts.

Respondents were asked to rate their care, the confidence they had in their doctors and nurses, and to give their views on whether there were enough nurses to provide the care they needed.

The 2010 nurses' survey (RN4CAST-England study) gathered information from nearly 3000 registered nurses working on general medical and surgical wards from a representative sample of 31 (46 hospitals) of the 161 trusts.

The nurses were asked about their workload during the day and various aspects of their working environment, such as resources, support, interpersonal relationships, leadership.

The data for the same 31 trusts from both surveys were then merged to estimate whether, and to what extent, the level of 'missed' nursing care in the different trusts affected how patients rated their care and their confidence in the clinical staff caring for them.

The level of trust and confidence patients expressed for nurses was of a similar magnitude to that they expressed for doctors.

But while three out of four respondents said they had confidence and trust in the clinicians treating them, only 60 percent felt there were always enough nurses to care for them. And one in 10 said that there were never or rarely enough nurses on duty.

Nurse numbers were strongly linked to how favourably patients viewed their hospital care.

This was rated as excellent by over half (57%) of those who felt there were always or nearly always enough nurses on duty, but by only around one in four of those who felt this was 'sometimes' the case, and by only 14 percent of those who never or rarely felt this.

The nurse survey showed that workloads ranged from 5.6 to 11.6 patients each across the 46 hospitals.

After taking account of various influential factors, the researchers calculate that the likelihood of patients always saying there were enough nurses to take care of them were about 40 percent lower in hospitals where the average nurse took care of 10 patients than in hospitals where they took care of six.

The nurses felt that they didn't always have time to provide the necessary care. Some 7 percent felt this about pain management, but over (52%) half felt they didn't have enough time to talk to patients and relatives about how to manage care after discharge. And around two thirds (65%) felt they didn't have enough time to comfort/talk to patients.

The lower the patient:nurse ratio, the lower were the number of needed but 'missed' episodes of care. Lower workloads were also associated with better working environments which, in turn, were associated with fewer missed episodes of care.

And the greater the number of episodes of missed care, the less likely were patients to rate their hospital care favourably.

"The narrative that quality deficits in hospitals are due to 'uncaring' nurses is not supported by the evidence," write the researchers.

"On the contrary, our findings suggest that reducing missed nursing care by ensuring adequate numbers of [registered nurses] at the hospital bedside, and improved hospital clinical care environments are promising strategies for enhancing patient satisfaction with care."

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