Is it cost-effective to deploy more nurses on hospital wards?

What is it about?

Currently the National Health Service (NHS), in common with many health systems around the world, faces shortages of registered nurses. Common sense and a huge body of evidence suggest this is far from ideal to deliver high-quality patient care. In acute general hospitals, when there are fewer registered nurses, more patient care is missed, quality is reduced and patient outcomes are worse. But fixing the problem is likely to be expensive and it is important to ask if this is the best way to spend money in a resource-limited system. Are there alternatives to using registered nurses? In this paper, we bring together research evidence in a systematic review to help understand whether investing in registered nurses represents value for money. We also consider whether using support staff with lower qualification levels might provide a more cost-effective solution to nurse shortages. We found a lot of evidence: 22 studies with data from 5900 hospitals and over 41 million patients. Because the evidence is observational, there remains uncertainty around the cost-effectiveness of registered nurse staffing increases, although evidence is generally favorable with the possibility that increases in nurse staffing are highly cost-effective if using criteria that would be applied to selecting new drugs to be adopted in public health services. Increasing the proportion of registered nurses in the ward team (so-called 'skill mix increases') could save money because hospital stays are shortened and the costs of treating complications is reduced. The evidence of this review lends no support to policies that maintain or increase the size of the nursing workforce through skill mix dilution. In absolute terms, the evidence is limited but the conclusions are clear. Increasing the proportion of registered nurses is associated with improved outcomes and reduced net costs. Conversely reducing skill mix increases costs and makes outcomes worse.

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Photo by Martha Dominguez de Gouveia on Unsplash

Photo by Martha Dominguez de Gouveia on Unsplash

Why is it important?

Showing that increased registered nurse staffing levels are linked to improved outcomes is not sufficient to provide a case for increasing them. Other options, including the use of support staff, are potentially less expensive, because of lower wages and training costs. However, this might affect the quality of care. In the face of budgetary constraints and workforce shortages, the relative costs and benefits (i.e. cost-effectiveness) of different investments need to be considered. Bringing together all the evidence to answer this question is essential as health systems around the world have to consider how best to address nurse shortages. • Evidence supports future investment in registered nurses as a cost-effective approach to staffing wards. • Strategies to address nursing shortages that lead to a dilution of the skill mix are likely to lead to worse patient outcomes and potentially higher overall costs of care.

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