SummedEt6 1996 Volume 9, No. 2 Skill Mix Literature Review by Dawn Friesen Review and analysis of the literature on skill mix In a time of fiscal restraint and health care restruc- turing, different skill mix ratios may represent one way to maintain high quality patient care while man- aging nursing costs.' While skill mix is not new, it is a highly complex and controversial concept,2and the issues and options surrounding it warrant thorough examination. Historically, it has been nursing shortages which have led to the development of innovative ways of providing safe patient care. The philosophy of team nursing originated after World War 11. Lambertsen has described team nursing as a patient-centered philoso- phy of nursing care and showed it to be an efficient and cost-effective way to administer nursing3 Team nursing is based on the philosophy that teams com- posed of members with varying skill levels can con- tribute to patient-centered nursing care, if that care is coordinated by a professional nurse. While team nursing is cost-effe~tive,~ it has the dis- advantage of being associated with an "old" way of doing things - task-oriented nursing and a diminution of nurse autonomy and knowledge-based practice. In contrast, primary nursing care offers the advantages of better continuity of care, increased autonomy for nurses, and the promotion of knowledge-based pro- fessional practice, but it is less cost-effe~tive.~ In view of these factors, it may prove beneficial to combine the financial advantages of team nursing with the profes- sional role of the nurse in primary nursing. Indeed, this may be a close "fit" with how nursing is actually being practised in some institutions. nursing care through restructuring its delivery has been an increased focus on the configuration of staff mix and the roles and functions of each level/category of worker.6Clear definition of the tasks and roles of all care providers will enhance this movement, which is addressed by the patient-focused care initiative. Man- they has warned that expediency may threaten a re- turn to structuring work around tasks and skills, in- stead of the more professional and satisfying mode of structuring it around patients' needs.6This problem may be prevented within a philosophy of patient- focused care. The ultimate goal is to adopt innovative staffing patterns which recognize and effectively use the differing levels of education, competence and ex- perience which exist among nurses, as well as between nurses and ancillary nursing personnel. A crucial de- terminant here is the determination of the optimum skill mix for patient care. One of the results of the drive to reduce the costs of 48 Healthcare Management FORUM
Transcript
SummedEt6 1996 Volume 9, No. 2
Skill Mix Literature Review
by Dawn Friesen
Review and analysis of the literature on skill mix
In a time of fiscal restraint and health care restruc- turing, different skill mix ratios may represent one way to maintain high quality patient care while man- aging nursing costs.' While skill mix is not new, it is a highly complex and controversial concept,2 and the issues and options surrounding it warrant thorough examination.
Historically, it has been nursing shortages which have led to the development of innovative ways of providing safe patient care. The philosophy of team nursing originated after World War 11. Lambertsen has described team nursing as a patient-centered philoso- phy of nursing care and showed it to be an efficient and cost-effective way to administer nursing3 Team nursing is based on the philosophy that teams com- posed of members with varying skill levels can con- tribute to patient-centered nursing care, if that care is coordinated by a professional nurse.
While team nursing is cost-effe~tive,~ it has the dis- advantage of being associated with an "old" way of doing things - task-oriented nursing and a diminution of nurse autonomy and knowledge-based practice. In contrast, primary nursing care offers the advantages of better continuity of care, increased autonomy for
nurses, and the promotion of knowledge-based pro- fessional practice, but it is less cost-effe~tive.~ In view of these factors, it may prove beneficial to combine the financial advantages of team nursing with the profes- sional role of the nurse in primary nursing. Indeed, this may be a close "fit" with how nursing is actually being practised in some institutions.
nursing care through restructuring its delivery has been an increased focus on the configuration of staff mix and the roles and functions of each level/category of worker.6 Clear definition of the tasks and roles of all care providers will enhance this movement, which is addressed by the patient-focused care initiative. Man- they has warned that expediency may threaten a re- turn to structuring work around tasks and skills, in- stead of the more professional and satisfying mode of structuring it around patients' needs.6 This problem may be prevented within a philosophy of patient- focused care. The ultimate goal is to adopt innovative staffing patterns which recognize and effectively use the differing levels of education, competence and ex- perience which exist among nurses, as well as between nurses and ancillary nursing personnel. A crucial de- terminant here is the determination of the optimum skill mix for patient care.
One of the results of the drive to reduce the costs of
48 Healthcare Management FORUM
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Issues related to skill mix
tial threat it poses to the jobs, roles and professional- ism of nurses. According to Morris, skill mix may threaten nurses with "a loss of identity, power and job^."^'^ 695) Gibbs, McCaughan and Griffiths* note that some nurses fear losing the "hands-on" aspect of nurs- ing as the role becomes more supervisory. Manuel and Alster' suggest that reducing the proportion of RNs in the staff mix may place heavier demands on the time and expertise of the remaining RNs. Skill mix may also lead to conflict and alienation between nurses and administrators, especially if RNs come to believe that staffing decisions are being based solely on cost con- siderations, without sufficient regard to quality of care. This is obviously a strong influencing factor which cannot easily be dismissed. Using unlicenced personnel for direct patient care presents yet another danger to RNs. Instead of being "freed" to practise professional nursing, they may be expected to care for larger numbers of patients with the support of fewer professional colleagues, at a time when patient acuity is rising."P 2 1 ) Professional nurses will also be expected to assume responsibility for supervising increasing numbers of non-professionals.
If nurses take a protectionist position in response to change - as they may well do, in the current context of Canadian health care reforms and job market concerns - there is likely to be a negative reaction to any proposed change in skill mix. However, while some RNs may feel threatened, Estaugh suggests that this apprehension is unwarranted; the "development of an efficient staff-mix criterion in nursing should en- hance nursing's rising sense of pr~fessionalism."~'~ 57")
Reassuring RNs that there are advantages to skill mix may help to reduce negative attitudes toward it. One positive aspect, for example, is that non-nursing tasks may no longer take up patient teaching time. Part of the rationale for promoting skill mix is to release the qualified nurse to perform activities that require high levels of skill and knowledge and to supervise the work of other team member^.^.'^ It is possible that licenced practical nurses (LPNs) and nursing assis- tants will see changes in skill mix as an opportunity for an enhanced role.
identified as a deterrent to instituting skill mix, no conclusive support for this has been found in the re- search literature."13 T~wnsend '~ suggests that outcome measurement tools limit the evidence that can be used to either support or reject particular nursing care de- livery models with respect to their impact on the qual- ity of patient care. This poses a challenge for future research. The literature review unearthed no research
One major difficulty related to skill mix is the poten-
While compromised quality of patient care has been
which examined the impact of changing the RN ratio or mix on care outcomes. Most articles related to di- minished quality of care were not based on research.
Mallison identified two studies which dealt with compromised quality of care." The first study com- pared two general medical units, one of which was staffed to capacity with RNs and the other which was understaffed. The study found that patients tended to stay longer on the understaffed unit, causing the hos- pital to lose more money than it saved by employing fewer RNs. This comparison, however, is not pertinent to this discussion, because skill mix involves changes in the staff mix, and is not the same thing as under- staffing. The second study found that hospitals with a higher proportion of RNs had lower mortality rates. Although this may be the case, the mortality rate alone is not a sufficient indicator of quality patient care.I6
On the topic of patient safety and quality patient care, Marck suggests that "the use of properly trained and supervised AHCW's (auxiliary health care worker) to perform specific tasks for patients or clients with stable health care needs and predictable response patterns is both an appropriate and effective use of reduced health care dollars. [Similarly] the use of AHCWs to perform non-patient tasks that do not require nursing judgement (some do) is also respons- ible management in health care.1117(p.10)
Marck cautions, however, that "using AHCWs in the hope of saving dollars where the knowledge, judgement, and skills of registered nurses are actually required is unsafe, can result in patient harm, is based on an incorrect assumption that registered nursin care is driving the increased costs of health care." 7(p10)
Staffing mix, as proposed for hospital-based practice, would obviously not exclude RNs, who would still be available to offer knowledge, judgement and skills at the appropriate level. Other health care workers would provide care under the guidance of an RN.
One concern related to implementing a skill mix model is that RNs are not sufficiently prepared to di- rect and monitor the activity of other health care per- sonnel. Kennerly states that "the introduction of a broadened role for unlicensed personnel adds a new dimension to the su ervisory responsibility of the reg- istered nurse. 'rlO(p 3h7PGardner6 suggests that the con- cept of administrative control is embedded in the structure issue of skill mix. Nursing has long advo- cated the need to have administrative control over all personnel performing nursing services. Skill mix heightens the real and unresolved issue of nursing's control over the non-nursing functions which support it. Having control implies a greater degree of coordi- nation of patient care services; however, it also gener- ates costs related to the supervision and management of these support personnel.',6
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A study by Hesterly and Robinson' reports that in- troducing patient care assistants and training RNs to direct and monitor the activities of other staff resulted in a significant cost-savings over primary nursing. After identifying their supervisory inadequacies, John- son" invested in a massive program to train RNs to manage, monitor and delegate to the staff helping them provide care. Implementation of this program realized a significant reduction in the cost-per-patient- day on the nursing units at the 34 facilities where the program of unlicenced care providers was instituted. Johnson does not include the details of the staffing mix, but does suggest that savings were achieved by a reduction in agency nurses, an increase in LPNs and an increase in technicians. The shift in staffing re- ported was toward fewer RNs. Sherman has also noted that RNs require particular knowledge, skills and attitudes to facilitate a team (skill mix) appr~ach .~
Shukla's'' research supports skill mix. Three nursing structures (modular, team and primary) were evalu- ated in this study. The primary nursing unit was staffed by 100% RNs; the modular unit was staffed with 50% RNs and 50% LPNs; and the team unit was staffed with 50% RNs, 25% LPNs and 25% aides. The study was limited to medical/surgical units, and the same amount of direct care was provided on each of the three units. The units were similar in size, configu- ration, support systems, experience of nurses, type and severity of patients, quality of care rendered and infection rate. The duration of the study was ten months. The independent variable was the nursing structure, or the difference in skill mix, between the nursing units. Shukla concluded that team nursing was the most cost-effective model and that no signifi- cant difference existed among the units with respect to the quality of nursing care as measured by both nurses and physicians. The infection rate was also com- parable on these units. While representing useful re- search in support of skill mix, this study does not offer details on what may constitute the "ideal" skill mix.
Estaugh performed a production function study across 29 American hospitals over a four-year period in order to evaluate the impact of the nurse extender (which has been defined by Manthey as a "technical assistant to an experienced RN as a primary partner- ship.")"" 5"3'Re~ult~ suggest that nurse extenders and RNs complement each other and do not compete with each other on the team. Furthermore, the results show that employment of nurse extenders reduces wasted labour and enhances productivity. While this study supports the utilization of non-RN staff, it does not suggest the best ratio of caregivers.
Cost-savings motivated the redesign of the entire nursing care delivery system at a hospital in Gainesville, Geor ia by Barton, Kunkle, Tucker and Robinson Bailey.2'A 38-bed medical / cardiology unit
was used as a test site. In this study, managed care was defined as a delivery system composed of clearly delineated roles and tasks for three skill levels of nurs- ing personnel - the RN, the LPN and the nursing as- sistant. Implementation of managed care showed sig- nificant changes in pre- and post-staff mix ratios. The study report includes a detailed list of particular tasks and roles of each level of caregiver. Three areas were evaluated as part of the move to managed care: finan- cial results, quality improvements and staff satisfac- tion. Financially, patient care staff were optimized by changing the skill mix from 46% RNs to 37% RNs; from 49% LPNs to 37% LPNs; and from 4.8% NAs to 26% NAs. While instituting this ratio change, the unit increased its capacity from 30 to 38 patients.
Changing the skill mix to substitute unlicenced workers in a lower pay category resulted in a 1990 labour cost of $801,840 US and a savings of $172,160 US. While skill mix obviously succeeded in reducing costs, it also complicated the process of regulating staff levels on a daily basis. Other significant findings: the RN staff met all expectations and expressed in- creased job satisfaction as a result of more time for assessments, more control over the team, and better communication with physicians. The LPNs experi- enced greater job satisfaction as a result of improved resource availability and an increase in their value as team members. Problematic areas included discharge planning and documentation of PRN medications.
Fritz and Cheeseman2' implemented the use of Pa- tient Care Specialty Technicians (PCST) to change the skill mix from 100% RNs to 75% RNs and 25% PCSTs in ICUs in a major U.S. hospital. The article focused on the development of the PCST role and subsequent training provided. The authors identified potential cost-savings, but none were realized given the trainin costs incurred. Luckenbill Brett and Crabtree Tonges conducted a pilot study on redesigned nursing prac- tice based on the ProACT Model on a 32-bed surgical orthopedic unit. This budget-neutral model uses fewer RNs with increased clinical and non-clinical support. Data regarding skill levels and skill mix were not in- cluded. Results suggest that fewer RNs with increased support can provide high quality, efficient care; cost reduction, however, was not conclusive.
One limitation of this literature review is that none of the articles discussed are Canadian studies. British2
studies have indicated that nurs- and American ing shortages and recruitment problems prompted the move toward staff mix alternatives. This is not a cur- rent problem in Canada and may well influence the receptivity of RNs to changes in skill mix. Another caveat to consider when reviewing the literature is that different jurisdictions apply different roles and functions to various levels of health care providers ( e g , the functions of the LPN in some American
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states extend well beyond the scope of practice of LPNs in Canadian provinces at this time). These dif- ferences make comparisons difficult.
Research implications The dearth of research studies, in particular data
from Canadian hospitals, points to the need for fur- ther research in this area. Gathering data from hospi- tals on current skill-mix ratios would provide a good starting point for research and serve as a useful com- parison for other organizations. Examining the fin- ancial implications of current and future skill mix ratios would assist health care planners and manage- ment to integrate possible variations of skill mix. Questions to guide research could include: How does acuity, volumes, activity and resource intensity affect skill mix? What is the experience across Canada with skill mix? What is the cost of various skill mix ratios (perhaps including all-RN staffing)? What is the posi- tion of professional associations regarding guidelines for skill mix? What legislation promotes or limits vari- ations in skill mix? What outcome criteria have been identified to assess variable skill mixes? What are nurses’ attitudes to skill mix issues?
art, is particularly open to manipulation when economies have to be made.” Planners must clearly identify the objectives to be achieved by redesigning care delivery.24 Studies must be undertaken to provide the necessary information base for making and de- fending decisions about skill mix. Effects on providers and the resulting patient outcomes must be exam- ined.25’26 Brooten and Naylor recommend that nurse dose (the amount and type of nursing needed to affect patient outcomes) undergo analysis at the system level and at the patient McManus and Pearson iden- tify the need to use clearer definitions and more con- sistent methods in studying nursing service structures, and determining nursing costs, and the interrelation- ships among the variables.27
Conclusion The number of nursing staff required to care for a
particular case-mix of patients varies according to in- ternal and external factors. The limited research avail- able on skill mix ratios and the situation of each insti- tution do not provide much direct guidance for con- sidering skill mix ratios. Institutional skill mix statis- tics, a certain degree of intuition and calculated risk- taking may prove to be the forces guiding appropriate skill mixes in our current situation. In view of the wide diversity of nursing care provided within acute care, each unit may require a particular skill mix im- plementation. Crucial changes that are required to in- corporate skill mix alternatives include the education of existing staff for their new role(s) - in particular
Morris7@ 695) suggests that ”skill mix, being an inexact
supervisory skills for RNs - and the preparation of a new category of unlicenced caregivers. Heath suggests that “careful consideration of skill mix offers much in terms of aligning services more effectively and more appropriately to the health needs of local populations.”
References and notes
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Morris M. Nurses must face skill-mix reality. British Journal of Nursing 1992; l(14): 695. Gibbs I, McCaughan D, Griffiths M. Skill mix in nursing: a selective review of the literature. Journal of Advanced Nursing 1991; 16: 242-249. Hesterly SC, Robinson M. Alternative caregivers: Cost-effective utilization of RNs. Nursing Adminis- tration Quarterly 1990; 14(3): 18-23. Kennerly SM. Implications of the use of unlicensed personnel: A nursing perspective. Focus On Critical Care 1989; 16(5): 364-368. Kirby KK, Garfink CM. The University Hospital nurse extender model - Part 1, An overview and conceptual framework. Journal of Nursing Adminis- tration 1991; 21(1): 25-30. Notter J. Skill mix is not grade mix. British Journal of Nursing 1993; 2(7): 351. Sheehan A. Skill mix does not work. British Journal of Nursing 1993; 2(5): 256. Townsend MB. Defining value added. Nursing Economic$ 1993; ll(6): 382. Mallison MB. Cadillac or Chevrolet nursing? Look under the hood. American Journal of Nursing 1992; 92(1): 7. Wray NP, Ashton CM, Kuykendall DH, Petersen NJ, Souchek J, Hollingsworth JC. Selecting disease- outcome pairs for monitoring the quality of hospi- tal care. Medical Care 1995; 33(1): 75-89. Marck P. The problem with good nursing care.
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