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Abstract
Objectives Omissions and delays in delivering nursing care are widely reported consequences of staffing shortages, with potentially serious impacts on patients. However, studies so far have relied almost exclusively on nurse self-reporting. Monitoring vital signs is a key part of nursing work and electronic recording provides an opportunity to objectively measure delays in care. This study aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and adherence to a vital signs monitoring protocol.
Design Retrospective observational study.
Setting 32 medical and surgical wards in an acute general hospital in England.
Participants 538 238 nursing shifts taken over 30 982 ward days.
Primary and secondary outcome measures Vital signs observations were scheduled according to a protocol based on the National Early Warning Score (NEWS). The primary outcome was the daily rate of missed vital signs (overdue by ≥67% of the expected time to next observation). The secondary outcome was the daily rate of late vital signs observations (overdue by ≥33%). We undertook subgroup analysis by stratifying observations into low, medium and high acuity using NEWS.
Results Late and missed observations were frequent, particularly in high acuity patients (median=44%). Higher levels of RN staffing, measured in hours per patient per day (HPPD), were associated with a lower rate of missed observations in all (IRR 0.983, 95% CI 0.979 to 0.987) and high acuity patients (0.982, 95% CI 0.972 to 0.992). However, levels of NA staffing were only associated with the daily rate (0.954, CI 0.949 to 0.958) of all missed observations.
Conclusions Adherence to vital signs monitoring protocols is sensitive to levels of nurse and NA staffing, although high acuity observations appeared unaffected by levels of NAs. We demonstrate that objectively measured omissions in care are related to nurse staffing levels, although the absolute effects are small.
Study registration The data and analyses presented here were part of the larger Missed Care study (ISRCTN registration: 17930973).
- Nursing staff
- vital signs
- patient deterioration
- retrospective study
- observational study
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Footnotes
Collaborators The Missed Care Study Group comprises Peter Griffiths (University of Southampton, Health Sciences, National Institute for Health Research Collaboration for Applied Health Research and Care (Wessex), Karolinska Instutet, Department of Learning, Informatics, Management and Ethics,Portsmouth Hospitals NHS Trust, Clinical Outcomes Research Group), Jane Ball (University of Southampton, Health Sciences, National Institute for Health Research Collaboration for Applied Health Research and Care (Wessex), Karolinska Instutet, Department of Learning, Informatics, Management and Ethics), Karen Bloor (University of York, Health Sciences), Dankmar Böhning (University of Southampton, Health Sciences), Jim Briggs (University of Portsmouth, Centre for Healthcare Modelling and Informatics, Portsmouth Hospitals NHS Trust, Clinical Outcomes Research Group), Chiara Dall’Ora (University of Southampton, Health Sciences, National Institute for Health Research Collaboration for Applied Health Research and Care (Wessex)), Anya De Iongh (Independent lay researcher), Jeremy Jones (University of Southampton, Health Sciences), Caroline Kovacs (University of Portsmouth, Centre for Healthcare Modelling and Informatics), Antonello Maruotti (University of Southampton, Health Sciences), Paul Meredith (National Institute for Health Research Collaboration for Applied Health Research and Care (Wessex), Portsmouth Hospitals NHS Trust, Clinical Outcomes Research Group), Alejandra Recio-Saucedo (University of Southampton, Health Sciences, National Institute for Health Research Collaboration for Applied Health Research and Care (Wessex)), David Prytherch (University of Portsmouth, Centre for Healthcare Modelling and Informatics, Portsmouth Hospitals NHS Trust, Clinical Outcomes Research Group), Oliver Redfern (University of Portsmouth, Centre for Healthcare Modelling and Informatics, Nuffield Department of Clinical Neurosciences, University of Oxford), Paul Schmidt (National Institute for Health Research Collaboration for Applied Health Research and Care (Wessex), Portsmouth Hospitals NHS Trust, Clinical Outcomes Research Group), Nicky Sinden (Portsmouth Hospitals NHS Trust, Clinical Outcomes Research Group) and Gary Smith (Bournemouth University, Faculty of Health and Social Sciences).
Contributors PG contributed to the design of the study and acquisition of research funding. PG and OCR interpreted the data, and drafted and revised the paper. AM contributed to the design of the study, statistical analysis plan, acquisition of funding and interpretation of data; advised on statistical analysis; contributed to drafting the paper and approved the final manuscript. AR-S and GBS contributed to the interpretation of the results and drafting the paper. Other members of the Missed Care Study Group contributed to the acquisition of funding and/or data, analysis, interpretation of analysis and approval of the paper.
Funding This project was funded by the NIHR Health Services and Delivery Research Programme (HS&DR 13/114/17). This paper draws on research and data reported in more detail in the NIHR Journal’s Library Publication: P. Griffiths J. Ball, K. Bloor, D. Böhning, J. Briggs, C. Dall’Ora, A. De Iongh, J. Jones, C. Kovacs, A. Maruotti, P. Meredith, D. Prytherch, A. R. Saucedo, O. Redfern, P. Schmidt, N. Sinden and G. Smith. "Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study." Health Services and Delivery Research Journal 2018; 6(38).
Competing interests PM, NS and PS are employees of Portsmouth Hospitals NHS Trust (PHT), which had a royalty agreement with The Learning Clinic (TLC) to pay for the use of PHT intellectual property within the Vitalpac product, which expired during the course of this study. DP and GBS are former employees of PHT. PS, and the wives of DP and GS, held shares in TLC until 2015. JB’s research has previously received funding from TLC through a Knowledge Transfer Partnership. PG was an unpaid member of the advisory group for NHS Improvement's work developing improvement resources for safe staffing in adult inpatient wards.
Patient consent for publication Not required.
Ethics approval The study was approved by the National Research Ethics Service, East Midlands – Northampton Committee Ref: 15/EM/0099.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.