Costs and cost-effectiveness of nurse staffing in acute hospital: a systematic review

Background Extensive research shows associations between increased nurse staffing, skill mix and patient outcomes. However, showing that improved staffing levels are linked to improved outcomes is not sufficient to provide a case for increasing them. This review of economic studies in acute hospitals aims to identify costs and consequences associated with different nurse staffing configurations in hospitals. Methods We included economic studies exploring the effect of variation in nurse staffing. We searched PubMed, CINAHL, Embase Econlit, Cochrane library, DARE, NHS EED and the INAHTA website. Risk of bias was assessed using a framework based on the NICE guidance for public health reviews and Henrikson’s framework for economic evaluations. Inclusion, data extraction and critical appraisal were undertaken by pairs of reviewers with disagreements resolved by a third. Results were synthesised using a hierarchical matrix to summarise findings of economic evaluations Results We found 22 observational studies conducted in the USA (15), Australia, Belgium, China, South Korea and the United Kingdom (3). Fourteen had high risk of bias and eight moderate. Six studies clearly favoured increased registered nurse staffing with improved outcomes and reduced or unchanged net costs, but most showed increased costs and outcomes. Studies undertaken outside the USA showed that increased nurse staffing was likely to be cost-effective at a per capita GDP threshold or lower. Three studies of skill mix favoured increased registered nurse skill mix, with reduced net cost and similar or improved outcomes. Discussion Despite the risk of bias, evidence is largely consistent and strongly favours increased skill mix. Evidence for the cost-effectiveness of increases in registered nurse staffing is less certain although it is likely to be cost-effective. In an era of registered nurse scarcity, the results strongly favour investment in registered nurse supply as opposed to using lesser qualified staff as substitutes. What is already known? What is study adds How this study might affect research practice or policy CREDiT (author contributions) Jane Ball, Chiara Dall’Ora, Peter Griffiths, Jeremy Jones, Paul Meredith acquired funding for the study Peter Griffiths, Jeremy Jones, Christina Saville designed the review and wrote the protocol Christina Saville undertook the searches Jane Ball, Jeremy Jones, Paul Meredith, Lesley Turner, Christina Saville undertook screening and application of the inclusion criteria Jane Ball, Chiara Dall’Ora, Peter Griffiths, Jeremy Jones, Paul Meredith, Lesley Turner, Christina Saville undertook data extraction and critical appraisal of included studies Christina Saville and Peter Griffiths prepared the first draft of the paper Peter Griffiths undertook data synthesis and drafted results Jane Ball, Chiara Dall’Ora, Peter Griffiths, Jeremy Jones, Paul Meredith, Lesley Turner, Christina Saville reviewed the first draft and provided critical comment and contribution to the discussion / suggested revisions. All reviewed the final draft Registration PROSPERO (CRD42021281202). ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Protocols ### Funding Statement This study was funded by the NIHR [Health and Social Care Delivery Research (award NIHR128056)] and the NIHR Applied Research Collaboration Wessex. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present work are contained in the manuscript