In Canada today, there has been an increased emphasis on health care budget and many health regions are exploring new and different ways to approach health care delivery. This is in response to the idea that health care performance does not match how much is spent on health in Canada. In 2017, the Fraser Institute released a study of Canada’s health system performance compared to 29 other countries, also with universal health care, and compared resource availability, use of resources, access to resources and quality and clinical performance (Alberta Health Services Performance Review, 2019). This study concluded that there was an imbalance between the value Canadians receive and the relatively high amount of money spent on health care (Alberta Health Services Performance Review, 2019).
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There is an idea that as part of the cost saving measures, health care systems will utilize licenced practical nurses (LPNs) more often where registered nurses (RNs) were previously needed. The assumption is that this would be more cost effective as an LPN is cheaper for the health care system to employ. Little research has been done that compares nursing skill mix to patient outcomes and cost effectiveness. This type of research can be time extensive, expensive, and their findings can differentiate based on location. While health care systems could save money hiring LPNs, patient outcomes relating to nurse skill mix and staffing ratio can be costly.
This study aims at finding commonalities within health care systems operations across the world looking specifically at the cost nursing skill mix and staffing levels have on patient outcomes and health care finance. A literature review of studies previously conducted, and ones used in newer systematic reviews can offer some insight into making such changes to the health care system. The search process for this literature review included using the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database with the following search words: skill mix, rn mix, staff mix, nurses, health care costs, health resource utilization, economics, finance, and cost. Inclusion criteria for the selected articles had to remain broad, to accommodate the minimal relevant articles found. Inclusion criteria for the selected articles included world-wide, peer reviewed studies and systematic reviews on nurse staffing and skill mix affect on healthcare cost and/or patient outcomes completed at acute care hospitals from reputable nursing journals. With limited recent studies within the last 5 years, data was also obtained from more historic articles dating back to 2005. Six articles and one discussion paper dating 2005-2009 met inclusion criteria and were taken from more recent systematic reviews. Using the PRISMA 2009 Flow Diagram, there were 341 records dating 2010-2020 identified through the main database searching, ### were duplicates and removed, ### were screened and excluded, ### full text-articles were assessed for eligibility based on specific inclusion criteria, and 10 articles were included in the literature review.
Review of Literature
The largest commonalities between the literature include the similar and different roles of nurses, the cost saving of increased nursing staff, and the affect skill mix has on patient outcomes.
Similar and differentiated roles of nurses
Although their comparison was done with enrolled nurses (ENs) and RNs, in an Australian study, Chaboyer et al. (2008) found the percentage of direct patient care to be higher for ENs than that of an RN (42.2%, 34.8%), while RNs spent more of their time doing indirect activities including care planning, medication preparation, patient rounds and meetings. While research has shown that the work of an EN and RN are similar, the knowledge that directs these activities are not the same and any activity out of a normal routine for an EN influences their scope of practice (Chaboyer et al., 2008). As well, the literature also shows that RNs are not always comfortable delegating to other care providers which fails to maximize the full benefits of RNs (Hasson et al., 2013). Another article, by Jacob, Mckenna & D’Amore (2015) discuss the quality of patient care and suggest that the proportion of RNs on a ward was more critical to patient outcomes, explaining that experience and theoretical knowledge has been linked with optimal patient outcomes. Higher skilled and experienced nurses have been shown to complete continual patient assessments and to communicate patient status’ to other health professionals for earlier detection of potential problems and earlier discharge times for patients (Jacob et al., 2015).
Similarily, McCloskey et al. (2014) found in their observational study that when compared to LPNs, RNs spend less time on indirect tasks (13.9%, 18.5%) while still providing direct patient care, taking on more responsibility than LPNs. It is the RNs role of planning and evaluating care that differentiates them from the other care providers, as well, RNs are more likely to take a team approach to care and find value and meaning from their interactions with patients (McCloskey et al., 2014). RNs focus on the patient and believe that nursing activities should originate from the patient’s needs and not from tasks, rules or routines and it is this qualified staff that achieves the most economic and effective health care delivery (Jacob et al., 2015). In the article written by Jacob et al. (2015), they also debate that it is economic factors, not professional needs, that have resulted in extensions to the roles of RNs and ENs across the world, as well as the development of newer roles such as the nurse practitioner. While extending the roles of different health professionals may result in improvements in efficiency, quality of care and professional satisfaction, RN retention has still been linked to the skill mix on the unit (Goryakin, Griffiths & Maben, 2011). Due to the differentiating roles, it is important to retain RNs where necessary to ensure the appropriate skill mix is met. As well, by increasing the roles of other health care professionals (including LPNs) and not retaining or decreasing RN staff, health care facilities will not be able to accommodate graduate nurses as there are not enough RNs to preceptor them. Graduate RNs will be unable to gain employment due to a lack of experienced preceptors to supervise them and economic constraints favour cheaper options (Jacob et al. 2015).
Increased nursing staff, cost savings and patient outcomes
Decreases in length of stay associated with higher nursing staff make up 90% of projected cost savings in a study done by Needleman, Buerhaus, Stewart, Zelevinsky & Mattke (2006) and that length of stay is associated more with hours of nursing care rather than the RN/LPN mix. This study also suggests that if fixed costs, costs that reflect patient volume, were fully recaptured, the net cost of increasing nursing staff would be much lower. There is also evidence in the Needleman et al. (2006) study that by raising the proportion of RNs from the 75th percentile (the units baseline staffing requirements) there is a cost savings of avoided outcomes of $73, 000, 000 and 980 avoided days, 4,997 avoided deaths. This suggests that direct cost savings for health services could be made by reducing adverse outcomes with an increase in nursing staff. However, studies focusing on nurse staffing struggled to assess the cost effectiveness of staffing more intensive nursing care in acute care hospitals as no strategy was clearly dominant over the others and cost effectiveness appeared to depend on the settings where the studies were conducted (Goryakin et al., 2011).
Rothberg, Abraham, Lindenauer & Rose (2005) examined labor costs and labor costs plus savings from decreased length of stay and found that for each decrement in patient to nurse ratio, nurse labour cost per patient increases and overall mortality declines. They found that the rate of incremental cost increase accelerates, while the rate of mortality decrease decelerates resulting in progressively higher incremental cost-effectiveness ratios for each one-patient decrease in the patient to nurse ratio. Rothberg et al. (2005) discusses how as nurses are assigned additional patients, the associated savings in labor costs per patient declines, however, the probability of a fatal error occurring increases, making higher patient to nurse ratios unattractive. Increasing the patient to nurse ratio by one result in 1.4 additional lives lost per 1000 admissions which costs $64,000 per life, which Rothberg et al. (2005) states could be prevented by decreasing the patient to nurse ratio instead. Griffiths, Ball, Murrells, Jones & Rafferty (2016) also found that mortality was higher in hospitals where RNs cared for more patients and that hospitals with six or less patients per RN had a 20% lower risk of patient death compared to having 10 or more patients per RN.
Findings were discussed in a meta-analysis included in Shekelle’s (2013) systematic review, which found a consistent relationship between higher RN staffing and lower hospital-related mortality. It states that an increase of 1 RN fulltime per patient reduces the odds of death in the intensive care unit by 9% and by 6% in a medical unit (Shekelle, 2013). Similarly, Griffiths et al. (2019) found in their retrospective longitudinal cohort study that for each day that a patient spent on a ward with RN staffing below the mean for that ward, the hazard of death was increased by 3% and each day of exposure to nurse assistant staffing below the mean was associated with a 4% increase in the hazard of death. As well, Griffiths et al. (2019) found that staffing model that included patient exposure to low staffing on all days of their hospital stay showed significant adverse effects from the lower RN staffing. While Griffiths et al. (2019) found no additional benefit in increasing nurse assistant staffing, which could include LPNs, they did find a linear relationship between RN staffing and mortality.
Stated in the Twigg et al. (2015) review, the Needleman et al. (2006) study and the Newbold (2008) study show that the greater use of RNs in preference to LPNs appears to pay for itself through improved patient outcomes and reduced hospital length of stays. Contrary to studies which recommend increasing nurse staffing, Newbold (2008) concluded that the cheapest option to improve outcomes was to change skill mix rather than the nurse patient ratio. Unlike Needleman (2006), however, Newbold (2008) found that increasing the percentage of RNs or decreasing the nurse patient ratio increased the cost per day ($4,030 USD for a survival rate of 976.2/1000 patients and $7,746 USD for a survival rate of 983.5/1000).
Sharma et al. (2016) studied the ideal staffing levels and staffing mix and found substantial variation with more than six times as many RNs in urban medical units, three times in urban surgical units and nine times in rural units. This was found for LPN staffing as well and a consistent pattern showed that highly staffed units had high levels of staffing of all providers. Sharma et al. (2016) state that variation in staff mix and staffing levels seemed to be driven by factors that also affected RN staffing, however, it remains to be tested whether this increased staffing across the board is a cost-effective means of improving patient outcomes.
In all three studies discussed in the Twigg et al. (2015) review, the incremental cost effectiveness ratio showed a cost associated with saving lives, with all costs within reasonable levels for the funding of interventions, however cannot be directly compared due to the different nature of the staffing comparisons they used. The Twigg et al. (2015) review shows mixed economic benefit to increasing nursing staffing or changing skill mix, as some studies show a saving and some a cost with results dependent on how variables were measured, the population they were measured in and how nursing staff or skill mix was conceptualized.
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Skill mix and patient outcomes
More evidence is surfacing that links nursing skill mix with patient outcomes in adverse patient events and mortality. Studies found that a higher portion of RNs is associated with a significantly lower mortality rate as well as lower rates of pneumonia, surgical site infections and post operative sepsis (Blegen, Goode, Spetz, Vaughn & Park, 2019). This same study, by Blegen et al. (2019) found that when more nursing care hours were provided by RNs, the rates of failure to rescue and hospital-acquired infections were lower in all of their 54 hospitals studied. A United States of America (USA) study by Patrician and Brosch (2009) found a decrease in medication errors by 86% for every 10% increase of RNs in the skill mix. This suggests that by removing RNs from routine patient care, there is a higher probability of critical changes in patient’s conditions being missed. Professional nurses (RNs) are able to detect early signs of complications, alert the rest of the healthcare team, and begin intervening to rescue the patient (Blegen et al., 2019).
Similarly, a systematic review published in 2019, concluded that out of 26 patient outcomes, 12 showed an inverse association with skill mix (Twigg, Kutzer, Jacob & Seaman, 2019). These outcomes were length of stay, ulcers, gastrointestinal bleeds, acute myocardial infarctions, restraint use, sepsis, mortality and cardiac arrest and there was a reduction in these 12 patient outcomes when a higher nursing skill mix containing more RNs was present (Twigg et al., 2019). However, for the remaining 14 patient outcomes in the Twigg et al. (2019) review, the results around skill mix was inconclusive. As well, although not specifically LPNs, the Griffiths et al. (2019) study finds that including an adequate number of health care assistants to compensate for deficits to RN staffing are important for maintaining patient safety, but acknowledge that findings in some studies show a negative effect to adding any level of assistant staff to RN staffing due to the reduction of skill mix. Sharma et al. (2016) also observed a negative correlation between staffing levels of different nursing providers, noting that the trade-offs between RN/LPN staffing to a certain degree could be the result of cost saving strategies, however, did not investigate its effect on patient outcomes.
Griffiths et al. (2016) also found that for each additional patient per health care worker (RNs excluded) was associated with a 1% increase in patient mortality on medical wards and 2% on surgical wards. They also found that higher staffing levels that excluded RNs was associated with higher levels of risk adjusted mortality showing no evidence for benefit from increasing health care worker staffing, whereas higher nurse (RN) staffing was significantly associated with lower mortality. As well, while health care workers may provide essential care, there is no evidence from large observational studies that health care workers presence can substitute for RNs to ensure patient safety (Griffiths et al., 2016).
Gaps and Limitations to Research
Many of the studies written about in this literature review use self reporting data to come to their conclusions. Self-reported studies can have common method bias, by either inflating, deflating or have no effect on the relationship and these results could over- or underestimate the effect of skill mix on patient outcomes (Twigg et al., 2019).
The literature search resulted in minimal reports of financial data in regard to skill mix and due to the historic data, the presented financial numbers that were found would not be relevant today. Contextual factors are important and deserve careful consideration when examining skill mix and implementing skill mix initiatives. These include sensitivity to existing professional roles, the needs of the health system, and support from government and relevant professional associations or unions (Cunningham, O’Toole, White & Wells, 2019). Cunningham et al. (2019) discusses the level of political engagement and involvement of health workers and professional groups in shaping health care policy as it relates to skill mix change and how the use of political power by the medical profession may influence decisions related to the implementation of skill-mix change. This insight also makes it difficult to come to one conclusion about appropriate nurse staffing skill mix and it is important to recognize that because of these contextual factors, cost effective strategies will change across healthcare systems. As well, even though studies have found that lower skill-mix has been associated with worse outcomes, they are only examining the proportion of RNs in the workforce. The independent examination of LPN staffing and patient outcomes cannot be determined in these articles.
While hospitals may be more interested in the financial impact, the studies are limited by not including both a societal and hospital perspective. As well, there are no randomized control trials in this area and all studies are based on observational data varying amongst health systems. The authors of these studies were unable to determine conclusively whether changes in nurse staffing levels or skill mix is a cost-effective intervention.
Conclusion and Recommendations
Reviewing the literature shows thata variation in nursing staffing levels and staffing mix is linked to patient outcomes and show that there is an opportunity to better distribute staffing for higher quality care. The literature included in this review conclude that although LPNs and RNs are capable on performing similar tasks, their approach and thought process behind these tasks vary. RNs bring more experience and theoretical knowledge to their practice which has been linked with optimal patient outcomes. With new health care roles emerging, the RN role is still important to protect for the future of nursing across the world. All studies in the review also conclude the benefit of increasing nursing staff on overall healthcare costs and patient outcomes, suggesting that although there may be a cost associated with increasing nursing staff, the long-term cost savings outweigh the initial costs. The affects nursing skill mix have on patient outcomes varied between studies. Although all studies showed evidence of improved patient outcomes when having more or adequate RNs on staff, there was mixed evidence around what the most appropriate skill mix is acknowledging that an adequate number of LPNs or health care assistants may be enough to compensate for the decrease in RNs and maintain patient safety, but exactly how many are unclear. The literature not only concludes an inconclusive ideal skill mix but suggests that diluting the skill mix may end up having negative effects.
Future studies should explore how health care providers, other than RNs, factor into the relationship between staffing and patient outcomes. This data could be used to better understand and optimize the appropriate skill mix for patient care. As well, data outlining the cost savings associated with these staffing changes and the cost savings of positive patient outcomes should also be collected and explored.
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