Skills matter

by Mary Chiarella, Professor of Clinical Practice Development and Policy Research, Faculty of Nursing, Midwifery and Health at the University of Technology Sydney.

Commissioner Garling recommends in his report that NUMs require a support person to relieve them of many of the administrative duties they currently do, to enable them to re-focus on managing clinical care.

No-one could possibly disagree with this recommendation and everyone I speak to is delighted by this recognition of their need.

But looking at all the tasks that nurses are doing to fill the gaps left by the absence of other staff, there is probably a need for extra non-professional staff to take up some of these other roles too. Much of this work could be undertaken by assistants in nursing (AiNs) and could provide them with a valuable career path into enrolled and registered nursing programs.

We would be foolish, indeed, not to welcome an increased cohort of AiNs who might be able to relieve clinical nurses of some of this work while providing much-needed support to the clinical team.

The difficulty here is we know budgets are limited. So, the question we need to think through is ‘what might be the cost to nurse staffing if we have more support staff’. This introduction of extra support staff must not come about through a further reduction in RN numbers. That would be false economy.

What is required is a sophisticated unit-by-unit review of skill mix and staffing based on a range of sensitive parameters other than simply Full Time Equivalent (FTE) head count. Workload tools are a useful starting point, but they only tell you how many bodies you need, not what level of skill those bodies are required to process. The danger with FTE calculations alone is that if it looks like a body is all you need, then a body may be all you get. But upright and breathing is not enough. It never was.

This is why Duffield et al’s work (Glueing it together) is so important, because it looks at the relationship between skill mix and adverse events. Governments and their advisory bureaucracies should ignore it at their peril. It is the biggest study ever undertaken examining the relationship between these two issues at a unit level and Duffield has received international acclaim as a result of it. For every 10% increase in RNs there is a 27% decrease in failure-to-rescue and we have wards in NSW where the percentage of RNs is already below 50%.

We have done a lot of work in NSW to encourage the introduction of many more junior nurses, both registered and enrolled, into the workforce and recently have been successful in increasing intakes of both new graduates and trainee enrolled nurses.

Much work has been done on reviewing our models of nursing care, and there has been a seismic shift away from patient allocation models of care delivery to team nursing models in an attempt to provide support for these less experienced members of the team (Chiarella & Lau, 2006, 2007).

But there is a need for a critical mass of RNs to maintain safe staffing, and we cannot continue to dilute our existing skill mix in order to provide the clinical non-nursing support that the RNs and ENs currently working in the system so desperately need. We need both quantity and quality, not either/or.

An increase only in upright and breathing bodies wandering around the ward is not only insufficient, it is a false economy. Adverse events cost money, much more money than extra RNs.