Research paper|Articles in Press

Nurse staffing and adverse events in residential aged care: Retrospective multi-site analysis

  • Dorika Nhongo
    CQUniversity, School of Nursing, Midwifery and Social Sciences, Bruce Highway, North Rockhampton, Qld, Australia
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  • Annie Holt
    School of Medicine, University of Notre Dame Australia, Fremantle, Australia
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  • Tracy Flenady
    CQUniversity, School of Nursing, Midwifery and Social Sciences, Bruce Highway, North Rockhampton, Qld, Australia

    Research Ready Grant Program (RRGP) Program Coordinator, School of Nursing, Midwifery and Social Sciences, Tertiary education division, B18 L1.32 Bruce Highway, North Rockhampton, QLD, 4701, Australia
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  • Amanda Rebar
    Motivation of Health Behaviours Lab, School of Health and Medical Sciences, Central Queensland University, 7/LG 15 North Rockhampton, QLD, 4702, Australia
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  • Kasia Bail
    Corresponding author.
    CQUniversity, School of Nursing, Midwifery and Social Sciences, Bruce Highway, North Rockhampton, Qld, Australia

    Gerontological Nursing, Nursing, Faculty of Health and Ageing Research Group, University of Canberra, 11 Kirinari Street, Bruce, ACT, 2617, Australia

    Synergy Nursing and Midwifery Research Centre, ACT Health Directorate, 2-6 Bowes Street, Phillip, 2606, Australia
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Published:October 19, 2022DOI:

      Summary of relevance

      • Issue: Quality of care is an ongoing issue in Australian residential aged care homes, with repeated reviews highlighting that workforce is a key aspect of neglect and poor resident outcomes.
      • What is already known: International residential aged care and Australian hospital evidence demonstrates more nurse staffing hours leads to lower rates of adverse events, but evidence specific to Australian aged care is lacking.
      • What this paper adds: Resident access to more registered nursing hours at night and on weekends decreased the chance of pressure injuries/skin tears or falls. Size of homes often determine nursing hours available.



      People living in residential aged care homes are entitled to a safe environment 24 hours a day, 7 days a week. Unfortunately, past evidence tells us this is not always the case and that our most vulnerable population experience high rates of adverse events.


      To determine whether after-hours shifts are associated with number of adverse events, independent of registered nurse staffing levels and residential aged care home size.


      Retrospective cohort design with multilevel modelling. Adverse events, registered nurse staffing and facility size were collected via routine reporting from ten homes (1020 beds) in one Australian state for three months in 2017.


      Residents records (n = 1560) of adverse events were collected from ten Residential Aged Care Homes with 1020 beds. An adverse event was reported, on average, every second shift per home. During afterhours shifts, there was an inverse association between nurse staffing and adverse events, such that lower nurse staffing was associated with higher rates of adverse events, specifically for falls and pressure injuries/skin tears. During day shifts, this effect was not seen.


      The findings support statements made at the Royal Commission into Aged Care Quality and Safety regarding the lack of adequacy of nurse staffing supervision during and after hours and may contribute to considerations of upcoming mandated registered nursing contact hours for 16 of the 24 hours in a day.


      During after-hour shifts, but not day shifts, having fewer nurses is associated with more likelihood of adverse event occurrences in Australian residential aged care homes. More research, in more sites and across more organisations, with better granulation across day, evening, night and weekend/public holiday shifts will improve understanding and responsiveness to the phenomena. Future research examining falls should include staffing levels.


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