NR 532 Week 5 Skill Mix Rationale Example

Skill Mix Rationale: Whether Three Midweek Evening Nurse Shifts on a Spine Unit Can Become Technician Shifts, Answered by Timing Which Evening Hours Only a Licensed Nurse May Work

Student Name

College of Nursing, Chamberlain University

NR 532: Healthcare Operational Planning and Management

Instructor Name

Month Day, Year

Skill Mix Rationale: Whether Three Midweek Evening Nurse Shifts on a Spine Unit Can Become Technician Shifts, Answered by Timing Which Evening Hours Only a Licensed Nurse May Work

The Proposal on the Table

During budget review, finance proposed a change to the staffing grid on the spine and neurosurgery floor where I am manager: swap one registered nurse for a patient care technician on the evening shift on Tuesday, Wednesday and Thursday. Those are the unit's busiest shifts, with seven nurses and three technicians planned. The saving would be the difference in loaded hourly rates, $52 for a nurse and $25 for a technician, over three eight-hour shifts a week, or about $33,700 a year.

Substituting a technician for a nurse saves money in every hour of work that either could do and costs more in every hour that only a licensed nurse may do. The question for this rationale is therefore not whether technicians are valuable, which they are, but which evening hours on this unit are which, measured rather than estimated.

How the Hours Were Measured

For two weeks, the evening charge nurse and I conducted a work sampling study on the Tuesday through Thursday evening shifts. Every 20 minutes, we recorded what each nurse and technician was doing, using nine categories defined in advance. We collected 1,008 observations of nurses and 432 of technicians. Each task category was then classified by who may perform it under the state nurse practice act and hospital policy: work only a registered nurse may do, work either may do, and work a technician is normally assigned.

What Evening Nurses Actually Do

Table 1 shows the share of evening nurse time in each category.

Table 1

Evening Nurse Time, Tuesday to Thursday, Two-Week Work Sample

Which Hours Are Which

Seventy-seven percent of evening nurse time on these shifts is work only a registered nurse may do. The remaining 23% could in principle be done by a technician, though first mobilization after spine surgery requires the nurse to assess neurological status and pain before the patient stands, so in practice about 14% of nurse time is fully transferable.

The substitution would remove eight nurse hours from a shift that uses about 56. Of those eight hours, roughly 6.2 are licensed work that the remaining six nurses would have to absorb, and about 1.1 hours would move to the added technician. At a nurse-to-patient ratio already at one to four on the busiest evenings, absorbing six more hours of licensed work means each nurse takes on about an hour more of assessments and medication passes on a shift when arrivals from recovery peak. That is where the cost of substitution sits.

Put in money terms, the saving is $27 an hour for a technician doing work a nurse was doing. On this shift, about three quarters of the hours the removed nurse worked cannot be done by the technician at all. The saving is real, but it is bought by spreading the licensed work across fewer licensed people at the hardest time of the day. The work sample also showed when in the shift that licensed work falls. Between 1500 and 1900, when most arrivals from recovery come up, 84% of nurse time was licensed work, compared with 68% after 2000. Removing a nurse would therefore bite hardest in exactly the hours the evening shift was built around.

What the Evidence Adds

The evidence on skill mix points the same way. Across 243 hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland, a richer mix of professional nurses went with fewer deaths and better patient ratings, and every 10-point drop in the professional share raised the odds of death by about 11% (Aiken et al., 2017). A longitudinal study of English hospitals found that low registered nurse staffing was associated with higher mortality and that additional nursing assistant staffing did not compensate (Griffiths et al., 2018). An American study of inpatient units found higher mortality among patients exposed to shifts staffed well below target (Needleman et al., 2011).

These studies are observational and describe many kinds of units, so they cannot tell us exactly what would happen on ours. But they are consistent with what the work sample shows: the hours a technician cannot replace are the hours most closely tied to patient safety after surgery.

Where Technicians Would Help

The work sample also shows where technicians are underused. On the day shift, which we sampled for comparison over one week, nurses spent 17% of their time on hygiene, repositioning, stable vital signs and supply retrieval, largely because the day shift carries three technicians for up to 23 patients and mobilization demands peak. Adding a fourth day technician on Tuesday through Thursday would cost about $31,200 a year and would move roughly 10 nurse hours a shift to technicians. That would not reduce the number of nurses, but it would give each day nurse more time for licensed work during discharges.

Recommendation

I recommend against substituting a technician for a nurse on the Tuesday through Thursday evening shift. The measured share of licensed work on that shift is 77%, the substitution would move very little transferable work, and the evidence associates dilution of registered nurse staffing with worse outcomes.

I recommend instead two steps. First, add a fourth technician on day shift on the three peak days, at about $31,200 a year, to relieve nurses of work a technician is normally assigned. Second, fund it by reducing weekend night technician coverage from two to one when the census is 16 or below, which the grid proposal shows happens on most Sundays; with twelve patients per technician at night, this saves about $10,400 a year. The net cost of about $20,800 is the price of keeping licensed hours on the shift that most needs them and using technicians where their hours can actually substitute.

References

Aiken, L. H., Sloane, D., Griffiths, P., Rafferty, A. M., Bruyneel, L., McHugh, M., Maier, C. B., Moreno-Casbas, T., Ball, J. E., Ausserhofer, D., & Sermeus, W. (2017). Nursing skill mix in European hospitals: Cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Quality & Safety, 26(7), 559-568. https://doi.org/10.1136/bmjqs-2016-005567

Griffiths, P., Maruotti, A., Recio Saucedo, A., Redfern, O. C., Ball, J. E., Briggs, J., Dall'Ora, C., Schmidt, P. E., & Smith, G. B. (2018). Nurse staffing, nursing assistants and hospital mortality: Retrospective longitudinal cohort study. BMJ Quality & Safety, 28(8), 609-617. https://doi.org/10.1136/bmjqs-2018-008043

Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037-1045. https://doi.org/10.1056/NEJMsa1001025