Nursing Skill Mix Research Articles

The influence of HIV/AIDS on the practice of primary care nurses in Jordan: Rhetoric and reality

The role of nurses in raising community awareness about HIV/AIDS is well-reported. However, little is known about the practice of Jordanian nurses and the role they play in the prevention and control of HIV/AIDS. This interpretive ethnographic study sought to illuminate the role of primary care nurses and examine the influence of HIV/AIDS on their practice. The study was undertaken in Jordan in three rural and three urban primary health-care centres. Data collection included participant observation, key informant interviews and document analysis. These data informed the development of descriptive ethnographic accounts that allowed for the subsequent identification of common and divergent themes reflective of factors recognized as influencing the practice of the nurse participants. The findings indicate that the rhetoric offered by all levels of administration and endorsed in policy is not reflective of the reality of practice. Poor resources and educational preparation, a limited nursing skill mix and access to professional development, lack of nursing leadership and role models, cultural beliefs and geographic isolation are factors that reduced the capacity of the primary care nurses to raise awareness and, therefore, influence the prevention and control of HIV/AIDS.

Exploring nursing skill mix: a review

The overall aims of the paper are to provide an overview of the subject, illustrate the need for further research and to raise awareness of the ongoing limitations of existing knowledge and present these to those involved in skill mix decision making. Over the last 20 years health care organizations across the globe have seen an increase in the pace of change. The continuing drive towards cost-effectiveness, quality of care and the clinical governance agenda are causing more and more managers to examine closely the mix of staff skills. This paper demonstrates that, despite 20 years of research and skill mix management in practice, there continues to be a tension between the use of qualified and unqualified staff, particularly, the cost and quality dimensions. The evidence which currently exists offers some limited support for the suggestion that redistribution of certain tasks in nursing could be possible and could contribute to strategies for meeting the demands of changes within health care delivery. Any reallocation of task, and substitution of qualified by unqualified staff, should be based on sound evidence and not merely on staff availability, service demand or apparent costs.

The Impact of Hospital Nursing Characteristics on 30-Day Mortality

Evidence indicates that hospital nursing characteristics such as staffing contribute to patient outcomes. Less attention has been given to other hospital nursing characteristics central to optimal professional practice, namely nurse education and skill mix, continuity of care, and quality of the work environment. To assess the relative effects and importance of nurse education and skill mix, continuity of care, and quality of work environment in predicting 30-day mortality after adjusting for institutional factors and individual patients characteristics. A cross-sectional analysis of outcome data for 18,142 patients discharged from 49 acute care hospitals in Alberta, Canada, for diagnoses of acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke between April 1, 1998, and March 31, 1999, was done. Mortality data were linked to patient demographic and comorbidity factors, institutional characteristics, and hospital nursing characteristics derived from a survey of all registered nurses working in acute care hospitals. Using multilevel analysis, it was determined that the log-odds for 30-day mortality varied significantly across hospitals (variance = .044, p < .001). Patient comorbidities and age explained 44.2% of the variance in 30-day mortality. After adjustment for patient comorbidities and demographic factors, and the size, teaching, and urban status of the study hospitals in a fixed-effects model, the odds ratios (95% confidence interval) of the significant hospital nursing characteristics that predict 30-day mortality were as follows: 0.81 (0.68-0.96) for higher nurse education level, 0.83 (0.73-0.96) for richer nurse skill mix, 1.26 (1.09-1.47) for higher proportion of casual or temporary positions, and 0.74 (0.60-0.91) for greater nurse-physician relationships. The institutional and hospital nursing characteristics explained an additional 36.9%. Hospital nursing characteristics are an important consideration in efforts to reduce the risk of 30-day mortality of patients.

Commentary. Nursing skill mix and staffing

Commentary. Nursing skill mix and staffing

"Realising the potential of critical care nurses": an exploratory study of the factors that affect and comprise the nursing contribution to the recovery of critically ill patients.

This study seeks to make evident the complexity of issues associated with the delivery of care by nurses to the critically ill. Emphasis had been placed on the results and implications of these for nursing practice. For a more in-depth account, the full report can be accessed on www.lscn.co.uk. Following multi-centre research ethics committee approval, 10 critical care units participated in the 3-month study. Data collection comprised 231 nurse interviews and 51 relative interviews during 33 observation participation periods. Analysis demonstrated that the context of the critical care unit, in terms of geographical layout, unit activity, case mix and skill mix of nurses, had a major effect on the ability of nurses to contribute to the recovery of the critically ill. The effectiveness of the nursing resource appeared to be a function of knowledge (theoretical and patient related), experience and exposure. Nurses who were unused to a particular environment were not seen to be as effective as those who were. A model was constructed that identified the central tenets upon which nursing care can be optimised or compromised. When nursing care was optimised the difference nurses made potentially decreased risk to patients, enabled timely patient progression and increased the potential for patient recovery. The results confirm that nurses have a significant contribution to make in the recovery of patients who have experienced critical illness. Recommendations are far reaching and include the need to develop a valid and reliable tool which addresses patients' need for nursing in terms of nurses' knowledge and experience, patient dependency and decreasing clinical risk across the continuum of care. Current nursing workload tools and patient:nurse ratios were seen to lack validity because they do not appraise the context in which care is delivered, define all nurses as equal and concentrate on activity rather than the effect nurses can have on the outcome of the critically ill.

Confusing rhetoric with reality: achieving a balanced skill mix of nurses working with children.

The option of separate registration in children's nursing has been a feature of nursing in the United Kingdom since 1919, but this is currently under review. The recently superseded governing body of nursing, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, has suggested that generic nurse registration with later specialization would be a more appropriate structure. Polarized views tend to dominate the debate over whether or not children's nursing should remain a discrete branch of nursing rather than simply another postregistration speciality. A long series of reports is often referred to in the debate, but the recommendations of these are often misconstrued and misrepresented. First, to provide a factual historical overview of the significant reports on the provision of child health care over the past 50 years, identifying the key principles of each, and to develop from this analysis reasoned conclusions regarding the priorities in skill mix for nursing children. Second, to propose an alternative framework for nursing skill mix that will ensure that children receive care appropriate to their needs, and that nurses are appropriately prepared for the level of service to be offered. The problems associated with expectations of universal provision of registered children's nurses for all children requiring nursing intervention have resulted from misunderstandings of the recommendations of key historical reports. In the light of evidence presented for the drive for abolition of specialist registration, and the main arguments of the polar stances of genericism or specialization, it is vital that alternative strategies are developed and debated. The proposed framework, based on pragmatism and key principles established from major reports, is discussed in an attempt to address the real issues; namely that all children are cared for by nurses who have adequate preparation commensurate with their needs, and that there is a strong career trajectory for all nurses working in the field of child heath.

Developing and supporting extended nursing roles: the challenges of NHS walk‐in centres

National Health Service (NHS) walk-in centres offer immediate access to nurse-led primary care. Forty 'pilot' centres are now open, of which nine are in London. In providing clinical assessment, health information and a limited range of treatments to users, they exemplify new nursing roles that are emerging in primary care. To describe the emerging roles of walk-in centre nurses, and explore the causes of role stress and review arrangements for training, development and support. METHODS; Semi-structured interviews with 29 managers and nurses from the nine London walk-in centres and with 10 stakeholders providing other primary care services near to three of the walk-in centres. Findings. Walk-in centre nurses are drawn from a wide range of clinical backgrounds. Emerging roles include diagnosing, developing clinical management plans, prescribing and discharging patients. Most find the roles challenging, but at times also stressful. There is no consensus on the most appropriate nursing skill mix for a walk-in centre nor on the core competencies required by the nurses working there. As a result there is no standardization of induction, training or support for walk-in centre nurses - particularly on the balance between taught and apprenticeship-type training. Agreement is required on the competencies required for walk-in centre nursing and on appropriate ways to develop and support nurses in their practice. Lessons could be learned from general practitioner training.

ICES Reports: Nursing Skill Mix and Experience Reduce Patient Mortality

ICES Reports: Nursing Skill Mix and Experience Reduce Patient Mortality

Defining the nursing contribution to patient outcome: lessons from a review of the literature examining nursing outcomes, skill mix and changing roles.

A review of the evidence to define the nursing contribution to patient outcome is presented. The review relies on work related to nursing sensitive outcomes, skill mix and changing roles. Methodological difficulties associated with these studies are highlighted. Areas requiring further research are discussed. It is suggested that experimental evidence is not always appropriate, when attempting to describe nursing activity. The authors advocate that new methodologies, in particular practitioner-centred research, are needed to unpack the nature of nursing.

Market, hospital, and nursing unit characteristics as predictors of nursing unit skill mix: a contextual analysis.

The objective was to examine the relative contributions of market, hospital, and nursing unit characteristics to the prediction of nursing unit skill mix. The strongest predictors of nursing skill mix were found to be the technological sophistication of the hospital, the volume of services offered, and the percentage of patients covered by managed care payors. The results suggest that skill mix on nursing units is buffered from market forces but is highly sensitive to hospital characteristics. These factors need to be taken into account when decisions are made about the allocation of personnel resources. In this article, the terms "nursing skill mix" and "nurse staffing" are used interchangeably.

Shifting the balance: nursing in primary health care

Fundamental changes over the last five years in the NHS, general practice and community care are influencing the shape of nursing in primary health care. This paper considers in particular the impact of general practitioner (GP) fundholding and discusses ways in which nursing in primary health care has responded in terms of changing skill mix in district nursing, health visiting and practice nursing and the growth of new nursing roles. The contribution of nursing to developing a needs-led and evidence-based service is discussed. This paper draws on exemplars from nursing practice in order to interpret policy and explain trends.

1447 Skill mix in oncology nursing, does it show implications for quality care?

Skill mix audit is becoming an ever important factor in the current health care climate as nursing resources come under scrutiny due to financial constraints. Following a recommendation from Health Service Management an audit tool was developed by a small group of senior oncology nurses which was specific to the oncology setting. The instrument was piloted with 15 qualified and unqualified staff with only minor adjustments being required The study lasted one week and involved 7 wards’ areas and 70 members of staff. This was a valuable exercise if looked at as an introduction to skill mix audit and supplied information that will be useful for future comparative studies. However the results highlighted the need to introduce some form of quality measurement and a patient dependency scale based on oncology patients.

Nursing skill mix substitutions and quality of care: an exploration of assumptions from the research literature

A comprehensive search of the research literature was undertaken to explore the relationship between skill substitution and quality of care. It was possible to identify three central assumptions based upon the studies reviewed. The first suggests that a rich skill mix of mostly qualified nurses is often an ineffective and inefficient way of providing health care. The second assumption is based on research which appears to indicate that a skill mix of mostly unqualified staff is an ineffective approach to health care provision. Finally, there is a plethora of research findings which suggest that the most effective and efficient way to provide health care lies in the employment of high numbers of qualified staff. This paper examines the evidence for each of these positions and highlights the inherent limitations of the underlying studies.

Nursing skill mix in neonatal care.

A large scale study of neonatal nursing was carried out with data collected from 56 sites (4 hospitals from each of the health regions of England). In the area of skill mix the key findings were: the largest segment of the neonatal nursing workforce is made up of staff nurses and staff midwives, and of these there are greater numbers of staff nurses; the E grade at 31% is the most frequently found, followed by the G (19%) and F grades (16%); vacancies were disproportionately high at staff nurse/staff midwife level; nursery nurses were employed for direct nursing care in 80% of units; nursing auxilliaries were employed in 70% of units, though in only half were they involved in the direct care of babies. Staffing policies were diverse and not clearly related to the type of unit or the numbers of designated intensive and special care costs. There was a tendency to employ more junior staff at night, the use of support staff varied widely, and in many units was at very low levels or absent. In addition to differing service demands that may affect the skill mix required, there is a clear need for the profession to address the questions that arise from changing roles and areas of responsibility in the spheres of management, teaching and clinical practice.

An appropriate nursing skill mix: survey of acuity systems in rehabilitation hospitals.

In a descriptive study, freestanding rehabilitation hospitals were surveyed to determine which acuity systems were in use in 1988. A questionnaire was developed by the researcher and sent to 83 freestanding rehabilitation hospitals in the continental United States. The results of the study showed that no one acuity system was being used. Additional findings were that the majority of the rehabilitation hospitals are not for profit, all of the hospitals have some type of accreditation, and there seem to be enough rehabilitation beds in the United States. Staffing patterns of the hospitals revealed that registered nurses and nursing assistants were the type of staff used predominantly; licensed practical nurses were used least. Ninety-one percent of the hospitals reported having registered nurses with associate's degrees or bachelor of science degrees, and 88% reported having nurses who had earned a diploma. Primary nursing care was the type of nursing care delivered most often, although many of the hospitals were using more than one form of care. Staff assignment was based on both census and acuity.

Accident and emergency work: a review of some of the literature

Accident and emergency (A and E) work is undergoing many changes including a revision of trauma patient management, examination of medical and nursing skill mix and the introduction of health care support workers. Such changes affect all members of the A and E health care team, including nurses whose role has traditionally been in the provision of continuing care of the patient and family. A and E nurses' response to change and subsequent professionalization is poorly documented within current health literature, much of which reflects medicine's response to change within A and E departments. The following literature review illustrates that the examination of A and E related issues involves some exploration of the 'open access' policy and its perceived effects upon the A and E department.

Skill mix continued

The latest contribution to the community nursing skill mix debate takes a more constructive approach than its predecessor, Lynn Young finds, with a strong emphasis on outcomes

Alternative review of community mix.

A review of community nursing skill mix has been carried out by the community health team in Newcastle.

Eric caines departs from the executive.

Outspoken NHS Personnel Director Eric Caines, well known for his controversial views on nursing skill mix and the pay Review Body, has announced his departure.

Nurse staffing levels and skill mix in accident and emergency departments.

There is currently great controversy about appropriate nurse staffing levels and skill mix in all areas. This has been brought about by changes in workloads, student allocation, the increasing use of support workers and persistent pressures on budgets.