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Employing too few permanent nurses on hospital wards was linked to higher patient death rates, longer hospital stays, and more readmissions, a study found.

Researchers said that relying on temporary staff to cover shortages was less effective and more expensive than hiring permanent registered nurses (RNs).

Analysis Across Four NHS Trusts

The longitudinal observational study was led by the University of Southampton, Southampton, England, and funded by the National Institute for Health and Care Research.

It analysed electronic healthcare records and staffing rosters from four NHS hospital trusts in England between April 2015 and March 2020.

The study involved 626,313 patients admitted to 185 acute care wards.

Published in the journal BMJ Quality & Safety, it assessed whether addressing understaffing through permanent posts was cost-effective and improved patient outcomes.

Researchers also examined links between staffing levels — both RNs and support staff, including healthcare assistants — and the risks for patient deaths, readmissions, and longer hospital stays.

Higher Mortality, Readmission, and Length of Stay

Patients on wards understaffed with RNs had a 5% mortality rate compared with 4% on adequately staffed wards.

Readmission rates were also higher on wards understaffed by RNs — 15% vs 14% — and average hospital stays were longer: 8 days vs 5.

Understaffing of healthcare assistants and other support staff showed similar trends.

Each day of RN understaffing during the first 5 days of a patient’s stay increased the 30-day risk for death by 8% and readmission by 1%.

If all five of the first days of a patient’s stay were understaffed, the average length of stay increased by 69%.

For nursing support staff, each understaffed day raised the 30-day mortality risk by 7% and length of stay by 61%. The 30-day readmission risk decreased slightly by 0.6%.

Saving Lives and Money

The estimated cost of inpatient care was £4173 per admission.

The researchers calculated that eliminating understaffing of both RN and support roles would cost an additional £197 per patient admission but could avoid 6527 of the 31,885 deaths recorded.

This would lead to 44,483 additional years of life in good health.

The estimated cost per healthy year of life gained was £2778, falling to £2685 when factoring in reduced sick leave and fewer readmissions.

When shorter hospital stays were included, the intervention became cost-saving, generating £4728 in savings per healthy year of life gained.

Temporary Staffing Less Efficient

Using temporary agency staff to fill gaps was significantly more expensive.

The cost per healthy year of life gained ranged from £7320 to £14,639 in such cases.

Cost-effectiveness was calculated by comparing the observed staffing shortfalls over the study period with the planned staffing levels.

“This study indicates the importance of prioritising investment in RNs employed on wards over support staff,” the researchers said. They added, “There are no shortcuts to employing enough RNs, as using temporary staff is more costly and less effective.”

Rob Hicks is a retired NHS doctor. A well-known TV and radio broadcaster, he has written three books and has regularly contributed to national newspapers, magazines, and online publications. He is based in the UK.