ARTICLE IN PRESS

0020-7489/$ - se

doi:10.1016/j.ijn

International Journal of Nursing Studies 44 (2007) 165–166

Editorial

Editorial: Outcomes of variation in hospital nurse staffing inEnglish hospitals

Keywords: Workforce planning; Nursing outcomes; Nurse staffing

www.elsevier.com/locate/ijnurstu

Inpatients in hospitals with lower nurse to patient

ratios are more likely to die or suffer complications than

patients in hospitals with higher nurse to patient ratios;

and nurses in these poorly staffed wards are more likely

to suffer from burnout and be dissatisfied with their

jobs. This is the main finding of the research reported by

Anne Marie Rafferty and her team in a landmark paper

published in this issue of the International Journal of

Nursing Studies (44 (2) 175–182), together with author-

itative commentaries on the paper by Klein (2006)

Normand (2006), and Bridges and Hyde (2006).

There have been a number of studies in the past,

which have reported an association between the number

of registered nurses and patient mortality but these have

often arisen from secondary analysis of data collected by

studies, which have focused on other aspects of hospital

resources. For example, secondary analysis and synth-

esis of trials of nursing led intermediate care in the UK

and elsewhere lent some support to the idea that

nursing-led units delivered better outcomes when the

qualified nurse to patient ratio was more favourable

(Griffiths et al., 2005, Griffiths and Wilson-Barnett,

2000).

In contrast to these studies, Rafferty et al.’s study in

the British NHS and similar research undertaken

previously in the USA (e.g. Aitken et al., 2002), focus

directly on the relationship between nurse numbers and

patient outcomes. Both Rafferty’s and Aitkin’s research

arrive at similar conclusions. Aitkin et al. (2002) propose

patient surveillance, early detection of risk and timely

interventions as some of the mechanisms linking nurse

numbers and patient outcomes; the effectiveness of

nurse surveillance is, not surprisingly, influenced by the

number of registered nurses available to assess patients

and monitor changes in their health.

Commenting at the launch of the study when it first

appeared online (Rafferty et al., 2006), the RCN

General Secretary Dr. Beverly Malone, pointed out that

e front matter r 2006 Published by Elsevier Ltd.

urstu.2006.12.001

the research ‘backs up what nurses have always known:

that nurse numbers do matter and that nurses make a

life and death difference to how well their patients

recover’. By contrast, those managing health services

seem to regard nursing as an infinitely plastic resource to

an extent that negates the frequent protestations of the

value of nurses from both health service managers and

politicians. Far too often decisions about the organisa-

tion of services both in and out of hospital have paid

scant regard to nursing practice and have had negative

consequences (Black, 2005).

We are pleased that the IJNS can play a part in

promoting the evidence of something that might seem

obvious but clearly is not. What nurses do matters in

tangible ways and is linked to ‘hard’ outcomes like life

and death as much as to ‘soft’ outcomes of patient

experience. If those managing health services want and

value nursing, and this research emphasises why they

should, then ensuring that there are sufficient and

suitably qualified nurses available to deliver it is crucial.

However, we should not be complacent. The link

between nurse staffing and patient outcomes is a

complex one and there are many other factors to

consider including the organisation management and

stability of the workforce (Coombs and Lattimer, 2006,

Hayes et al., 2006, Hurst, 2005). This research may not

be the last word on the matter and there are hidden

complexities and ongoing debates about a number of

issues including the merits of mandatory staffing ratios.

Adequate nurse staffing may be a necessary condition

for high quality care but it is surely not a sufficient one.

The nursing profession has too often been prepared to

assume that its mere existence should be equated with

uncontestable virtues such as ‘advocacy’, ‘caring’ and

‘holism’, which are easily said but less easily demon-

strated. A guest editorial in this journal recently issued a

challenge for nursing research to move from an

emphasis on descriptive research to analytic research

ARTICLE IN PRESSEditorial / International Journal of Nursing Studies 44 (2007) 165–166166

that directly informs practice (Hallberg, 2006). We hope

that in the future this journal will increasingly be a vehicle

for a research base that supports the genuine advance of

the practice of nursing in part at least by putting the easy

claims about ‘what nurses have always known’ to the test.

References

Aitken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., Silber,

J.H., 2002. Hospital nurse staffing and patient mortality,

nurse burnout, and job dissatisfaction. Journal of the

American Medical Association 288 (16), 1987–1993.

Black, N., 2005. Rise and demise of the hospital: a reappraisal

of nursing. BMJ 331 (7529), 1394–1396.

Bridges, J., Hyde, P., 2006. Outcomes of variation in hospital nurse

staffing in English hospitals: more nurses working differently?

International Journal of Nursing Studies 44 (2), 171–174.

Coombs, M., Lattimer, V., 2006. The safety, effectiveness and

costs of different models of organising care for critically ill

patients: literature review. International Journal of Nursing

Studies 44 (1), 115–129.

Griffiths, P., Edwards, M., Forbes, A., Harris, R., 2005. Post-

acute intermediate care in nursing-led units: a systematic

review of effectiveness. International Journal of Nursing

Studies 42 (1), 107–116.

Griffiths, P., Wilson-Barnett, J., 2000. Influences on length of

stay in intermediate care: lessons from the nursing-led

inpatient unit studies. International Journal of Nursing

Studies 37 (3), 245–255.

Hallberg, I.R., 2006. Challenges for future nursing research:

providing evidence for health-care practice. International

Journal of Nursing Studies 43 (8), 923–927.

Hayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian, J.,

Buchan, J., Hughes, F., Spence Laschinger, H.K., North,

N., Stone, P.W., 2006. Nurse turnover: a literature

review. International Journal of Nursing Studies 43 (2),

237–263.

Hurst, K., 2005. Relationships between patient dependency,

nursing workload and quality. International Journal of

Nursing Studies 42 (1), 75–84.

Klein, R., 2006. Outcomes of variation in hospital nurse staffing

in English hospitals: a lesson for policy makers. Interna-

tional Journal of Nursing Studies 44 (2), 167–168.

Normand, C., 2006. Outcomes of variation in hospital nurse

staffing in English hospitals: a case for investment?

International Journal of Nursing Studies 44 (2), 169–170.

Rafferty, A.M., Clarke, S.P., Coles, J., Ball, J., James, P.,

McKee, M., Aiken, L.H., 2006. Outcomes of variation in

hospital nurse staffing in English hospitals: cross-sectional

analysis of survey data and patient records. International

Journal of Nursing Studies 44 (2), 175–182.

Ian Norman, Peter Griffiths

King’s College, London, UK

E-mail address: ian.j.norman@kcl.ac.uk (I. Norman)