Temporary nurses ‘not long-term’ solution to staff gaps, warn researchers

UK researchers from a leading centre on workforce studies concluded that using temporary nursing staff to fill rotas only partially tackles the increased risk of patient death associated with staff shortages.

Avoiding low nurse staffing levels lowers the risk, especially when drafting in temporary registered nurses, but the risk remains elevated compared to when wards are fully staffed by permanent nurses.

This was the key finding from a University of Southampton study, which was published this afternoon in the journal JAMA Network Open.

The study was funded by the National Institute of Health and Care Research (NIHR) Health Services and Delivery Research Programme and the NIHR Applied Research Collaboration.

“This finding challenges the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety”

Research paper

Researchers analysed the data of more than 600,000 patient admissions across 185 wards at four acute trusts in England between 2015 and 2020 to measure the impact of staffing gaps, and the use of temporary registered nurses to fill them, on patient outcomes.

As previous studies have also found, the Southampton researchers’ data suggested that low levels of registered nurses correlated with a higher risk of patient death.

Lead author Professor Peter Griffiths said that the study did display the value of temporary staffing to avoid deaths, but argued that it also suggested that they were not a cost-effective way to plug gaps.

“Our study shows that addressing low staffing levels by using temporary staff to fill gaps is definitely beneficial in avoiding deaths on wards,” he said.

The harm associated with low staffing is greater than using temporary staff to rectify shortfalls.

“However, our findings challenge the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety.”

In the research sample, the researchers observed a roughly 7.9% higher risk for each day of low staffing among registered nurses, and a 7.2% higher risk for low nursing support staff numbers.

On days where temporary registered nurse levels were increased by 10% on normal levels, risk of death was found to be 2.3% higher.

No difference in elevated risk of death for patients was found between types of temporary staff – bank or agency.

Meanwhile, increasing the number of nursing support staff correlated with an increased risk of death for patients of 4%, with agency staff having a “larger adverse impact” than bank staff.

Despite the findings, the researchers said that more work was needed to fully investigate the impact of temporary staff on patient mortality.

They conceded that other research on the topic had yielded mixed conclusions. The report read: “Some studies have found a higher risk of adverse events with high levels of temporary staff.

“Unfamiliarity with the care setting is hypothesized to lead to inefficiency, reduced continuity, and, hence, increased risk to patients.

“However, other studies have found no adverse outcomes from using temporary staff to maintain staffing levels,” they said.

“Recent research highlights differences in the impact of external agency nurses and temporary staff directly employed by hospitals.”

Professor Griffiths pointed to the findings about seniority among staff, which suggested having more senior staff, including non-registered nursing staff, had benefit compared to less experienced personnel.

“Previous studies have supported a beneficial effect from using more senior staff within a team and our findings are consistent with this,” he added.

“This suggests the relatively new registered nurse associate role, which will increase the proportion of senior support staff on wards, does have some benefits.”

The study concluded that the benefits of avoiding low staffing were “greater” than the harms found from using temporary staff, but added: “Risk remained elevated if temporary staff were used to fill staffing shortages.

“While our findings show the importance of considering the mix of staff as well as absolute numbers, the largest effect sizes observed were those associated with low staffing.

“This finding challenges the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety.”

Responding to the publication of the research, Royal College of Nursing (RCN) England executive director Patricia Marquis said it was a "stark reminder" of the risks posed to patients by understaffing, and a display of the "ineffectiveness" of an overreliance on temporary staff.

“Often hospitals are forced to spend vital funds bringing in staff on a short-term basis to cover for long-term vacancies," she said.

"These temporary members of nursing teams play a vital and integral role in protecting patient care, and wards are far safer with them than without. They are highly skilled, but like their full-time colleagues, are still often left working in unfamiliar environments, with colleagues they have not met, and can still be working with too few staff.

“To protect patients, we not only need to improve nurse recruitment and retention on a more long-term basis, but also set safety-critical limits on the maximum number of patients a single nurse can be responsible for. Today, right across the NHS, staff are left caring for too many patients at a time. It's not safe, it’s not effective, and it's not acceptable.”