Diluting The Hospital Nurse Skill Mix Is Not In The Public Interest

Our study suggests that the NHS needs to focus on achieving safe registered nurse staffing levels as a means to achieve better outcomes for patients. Anything less won't do.
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Our research published this month in the BMJ Quality and Safety Journal on skill-mix and mortality rates should give everyone connected to the NHS - whether as a user, a provider of services or a funder - pause for thought.

People expect that when they go into hospital, the person they receive nursing care from is a trained and registered nurse - someone who has been recruited on the basis of having sufficient intellect and a caring attitudes, and who is then given education and clinical experience to understand health and illness, and develop the skills needed to deliver nursing care. It comes as a shock when I explain to people outside of health circles that this is not the case. Much of the hands on nursing care patients receive is delivered by support workers. They may look much the same as registered nurses (and the variety of uniforms doesn't help anyone to know who is who) but they are in-fact, health care assistants (HCAs); a large group of low-paid, unregulated staff who on average have received two-weeks (or less) training before they took up their post. Not two years, two weeks. And, if something should go wrong as a result of the care that support worker provides, can they be struck off to prevent them working somewhere else? No. Because despite review, they are neither registered nor regulated. There is no centralised list checking that staff in support roles such as these have the skills needed and behave appropriately given the privileged position of trust they hold. The nursing regulator - the Nursing Midwifery Council - does not cover health care assistants or other support workers, such as Assistant Practitioners. Nor do any of the other health regulatory bodies who are charged with protecting the public.

Yet these staff are relied upon increasingly heavily, making up larger proportions of the overall nursing team and taking on an ever-increasing array of activities.

So why are registered nurses not doing more of the fundamental care themselves? Why has care been delegated downwards? Are they 'too posh to wash' patients, or with their three year degree education have they become 'too clever to care'? No. The transition towards more care being delivered staff who have not had nurse training is not one that the profession - or indeed individual nurses - has chosen. When asked about how their jobs could be improved, most nurses say they wold like to spend more time on clinical hands-on care, not less.

The time available for direct care depend on overall numbers and the mix of the posts on a ward: how many registered nurses and how many support workers. It's what those of us working in health care refer to as the 'skill-mix'; a measure of what proportion of the nursing team are registered nurses, with the full registered nurse set of skills.

In recent years, we have once again had a nursing shortage. NHS trusts report great difficulty filling posts. Yet this shortage is not a force of nature - a drought that is beyond the system's control. It is, as the migrations advisory committee puts it, a problem of our own making. The health service in England chose not to train the number of registered nurses that had been judged as required. This time last year, Health Education England announced that despite the context of too few registered nurses, that they would be funding just 300 of 3,000 extra adult general nurse training places they had assessed as being needed. A few days later came the announcement of a new role: the 'nursing associate' - an option put forward to help reduce the 'reliance' on the registered nurse to deliver nursing care to patients.

The 'pragmatic' view I hear put forward, particularly in the context of too few registered nurses, is that we need enough pairs of hands on duty. We thus do not have the 'luxury' of worrying about who those hands belong to; the nursing 'skill-mix'. It is thought that it's the size of the total nursing team that counts (and so is counted) rather than the number of registered nurses and the amount of care they can provide to each patient.

Yet the research published today makes clear that this is an assumption that patients pay the price for. Our multinational research study of skill-mix found that the greater the proportion of professional nurses at the hospital bedside, the lower the mortality, the better the quality and safety of care, and the more likely that patients will express satisfaction with their care. Who provides the care makes a massive difference. In a hospital with average staffing and skill mix, for every 25 patients, just one professional nurse substitution with a nursing assistant or support worker was associated with a 21 per cent rise in the odds of dying. The results prompted the researchers to conclude that "diluting" the hospital nurse skill mix "is not in the public interest."

This research is consistent with a growing body of research showing that sufficient numbers of professional nurses providing direct care to hospitalised patients produces the best outcomes and avoids costly adverse care outcomes. Yet England has one of the lowest percentages among European countries of professional nurses at the bedside.

Our study suggests that the NHS needs to focus on achieving safe registered nurse staffing levels as a means to achieve better outcomes for patients. Anything less won't do.


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