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Alberta Heritage Foundation 
for Medical Research 


Nursing Skill Mix and 
Health Care Outcomes 


David Hailey, Christa Harstall 


December 2001 


Digitized by the Internet Archive 
in 2016 


J 




https://archive.org/details/nursingskillmixh2001hail 


IP-8 Information Paper 


Nursing Skill Mix and 
Health Care Outcomes 


David Hailey, Christa Harstall 


December 2001 


Additional information and comments relative to the information paper 
welcome and should be sent to: 


Director, Health Technology Assessment 

Alberta Heritage Foundation for Medical Research 

1500, 10104 - 103 Avenue 

Edmonton 

Alberta T5J 4A7 

CANADA 

Tel: 780-423-5727, Fax: 780-429-3509 


© Copyright Alberta Heritage Foundation for Medical Research, 2002 


Nursing Skill Mix and Health Care Outcomes 


Acknowledgments 

The Alberta Heritage Foundation for Medical Research is most grateful to the 
following persons for provision of information and comments on the draft 
report. The views expressed in the final report are those of the Foundation. 

Ms. Heather Crawford, Health Sciences Centre, Wimiipeg, Manitoba 

Dr. Phyllis Giovannetti, Faculty of Nursing, University of Alberta, Edmonton 

Dr. Arminee Kazanjian, British Columbia Office of Health Teclmology 
Assessment, Vancouver 

Dr. Patricia Marck, Alberta Association of Registered Nurses, Edmonton 
Ms. Debbie Phillipchuk, Alberta Association of Registered Nurses, Edmonton 


In preparing this report, the Foundation was assisted by a working parU^ that 
provided advice on the study. Participants in meetings of the working parU^ 
were: 

Ms. Debra Allen, Alberta Association of Registered Nurses, Edmonton 
Mr. Tyler Cleveland, Calgary Health Region 

Ms. Judy Dahl, Registered Psychiatric Nurses Association of Alberta, Edmonton 

Dr. David Hailey, Alberta Heritage Foundation for Medical Research (Chair) 

Ms. Christa Harstall, Alberta Heritage Foundation for Medical Research 

Ms. Sarah Hayward , Alberta Heritage Foundation for Medical Research 

Mr. Don Juzwishin, Alberta Heritage Foundation for Medical Research 

Ms. Barbara Lowe, Registered Psychiatric Nurses Association of Alberta, 
Edmonton 

Dr. Sue Ludwig, Alberta Health and Wellness, Edmonton 

Ms. Rita McGregor, College of Licensed Practical Nurses of Alberta, Edmonton 

Ms. Nikki Winters, Calgary Health Region 


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Nursing Skill Mix and Health Care Outcomes 


Contents 

Acknowledgments i 

Introduction 1 

Approach to the Study 2 

Competencies of Nursing Staff 3 

National nursing competency report 3 

Subsequent information on competencies 5 

Information from British Columbia (BC) 5 

Specific training programs 6 

Roles of LPNs in Canada 7 

Skill Mix of Nursing Staff and Patient Outcomes 9 

The AARN reviews 9 

Subsequent literature 10 

Other studies 11 

Other Issues 17 

Implications for RHAs in Changing Nursing Skill Mix 18 

Appendix A: Literature Review 21 

Appendix B: Excerpts from the B C Health Professions Council 

Scope of Practice Review 23 

References 30 

Tables: 

Table 1: Levels of autonomy for LPNs, RNs and RPNs 4 

Table 2: Shared and unique competencies for LPNs 4 

Table 3: Selected studies that considered skill mix and patient outcomes 14 


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Introduction 

This paper has been prepared following interest by the Calgary Regional Health 
Authority (now known as the Calgary Health Region (CHR)) and Alberta Health 
and Wellness in obtaining advice on the appropriate skill mix /staff mix of 
Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) in routine health 
care. 

Specifically, forecasts by the CHR indicated an increased demand for RNs o\^er 
the next five years due to loss of existing staff and increased volume of health 
services. In view of this, the CHR wished to investigate use of other health 
professionals in order to fully utilize available health professionals and possibly 
assist in alleviating staffing concerns. The CHR had received inquiries regarding 
its utilization of Licensed Practical Nurses and whether or not more LPNs could 
be incorporated into its staffing models. Increasing numbers of LPNs was seen 
as a means to meet an expected shortfall in nursing care, and would not replace 
RN positions. There was particular interest in changing nursing skill mix in the 
sub-acute care and mental health areas. These are expanding and would pro\hde 
an opportunity for new approaches to staffing mix. Use of Registered Psychiatric 
Nurses (RPNs) in areas previously utilizing RNs would be another option. 

It was also recognised that there could also be an increased demand for RPNs 
and that similar considerations of recruitment and appropriate skill mix might 
arise. 

Currently, the CHR employs about 6,800 RNs and 340 LPNs. Historically, for a 
variety of reasons, it has utilized a predominantly RN staff mix. 

Following discussion with representatives of the Regional Health Authorit} , 
Alberta Health and Wellness, and nursing professional bodies, it was agreed that 
the scope of the review described in this report would be as follows: 

Noting that there is interest in obtaining information on the competencies of 
RNs, RPNs and LPNs; on where the separation exists along the continuum of 
delivery of patient care between RNs', RPNs' and LPNs' competencies; on the 
relationship between skill mix and patient /management outcomes; and on the 
most effective and efficient skill mix in specific areas. 


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The objectives of the review will be: 

1. To summarise the shared and unique competencies of RNs, RPNs, and LPNs. 

2. To review empirical research that has examined the relationship between skill 
mix of RNs or RPNs and LPNs and client/ patient outcomes. There will be a 
focus on areas that are nursing sensitive such as wound management and 
rates of infections. 

3. To review empirical research on the relationship between skill mix of RNs or 
RPNs and LPNs and outcomes of different client /patient groups in specific 
areas such as acute care, sub-acute care, long term care, community care and 
home care. 

4. To comment on any implications for use of RNs, RPNs, and LPNs within the 
Calgary Health Region that may be suggested by the reviewed literature. 

The focus of the study is therefore on the link between nursing skill mix and 
outcomes and with an emphasis on the changes to the roles and competencies of 
LPNs in comparison with those of RNs and RPNs. 

The study may be of interest to a number of other RHAs in Alberta that reported 
in a recent survey conducted by Alberta Health and Wellness that they were 
actively examining /considering changes to the RN/LPN mix. 

Approach to the Study 

The study has been based on a review of the published evidence, obtained from 
electronic databases and from material supplied by professional bodies. Details 
of the literature search are shown in Appendix A. The focus was on those 
studies that considered outcomes related to skill mix or staffing and provided a 
comparison between LPNs and RNs or RPNs. Some reference was made in the 
reviewed literature to other staff classifications or titles. Non-RN nursing titles 
included licensed vocational nurses (LVNs), enrolled nurses, assistant nurses and 
auxiliary nurses. Other types of staff included trained medication aides (TMAs), 
nursing assistants (NAs), nursing aides, respiratory therapy technicians and 
obstetric technicians. 

Advice on the study and comments on drafts of the report were provided by an 
AHFMR working party that included representatives of the College of Licensed 
Practical Nurses of Alberta (CLPNA), the Alberta Association of Registered 
Nurses (AARN), the Registered Psychiatric Nurses Association of Alberta 
(RPNAA), CHR and Alberta Health and Wellness. 


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Competencies of Nursing Staff 
N ational nursing competency report 

Considerable detail on entry level competencies was provided in the 1997 
National Nursing Competency Report Tins notes that, generally, competencies 
are seen to have a variety of components or aspects, including, but not limited to, 
knowledge skills, attitudes, values, and judgments. Definitions of competence 
and competencies are included in entry level competencies for LPNs, RNs, and 
RPNs and information on which were unique to each group and which were 
shared. The details were derived from opinions from representatives of nursing 
groups throughout Canada and included lists of competencies for 1996, with 
projections for 2001. Each competency statement included was considered to be 
required by 65% or more of respondents from a particular nursing group. 

Tables 1 and 2 have been prepared from data given in Appendix 12 of the 
National Nursing Competency Report and give an indication of expected levels 
of autonomy for the different nursing groups and of shared and unique 
competencies. Table 1 summarizes the number of competencies for each nursing 
group in terms of levels of autonomy. The data reflect the expectations of 
increased autonomy for all nursing groups over the 1996-2001 period. LPN 
competencies relate more to stable than unstable health conditions, with 
autonomy in each of these areas projected to increase over that five year period. 

Table 2 lists numbers of shared and unique competencies for LPNs in 1996 and 
as projected for 2001. Competencies shared between the three nursing groups 
were also expected to increase by 2001 (Table 2). The data give some illustration 
of the overlap in the scope of practice for the three nursing groups. LPNs will 
typically be working together with RNs and RPNs. In part this will reflect 
changes to LPN competencies that have taken place over the last five years. 


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Table 1 : Levels of autonomy for LPNs, RNs and RPNs * 


All competencies 


Independent 

In consultation 

With direction 


1996 

2001 

1996 

2001 

1996 

2001 

LPN 

65 

107 

36 

73 

55 

40 

RN 

120 

189 

58 

81 

46 

34 

RPN 

132 

193 

81 

64 

24 

24 

Competencies addressing level ) 

of autonomy 



Independent 

In consultation 

With direction 


1996 

2001 

1996 

2001 

1996 

2001 

LPN 

12 

37 

36 

73 

55 

40 

RN 

65 

111 

58 

81 

46 

34 

RPN 

72 

118 

81 

64 

24 

24 

Competencies addressing stable health conditions 


independent 

In consultation 

With direction 


1996 

2001 

1996 

2001 

1996 

2001 

LPN 

1 

10 

32 

46 

18 

28 

RN 

32 

46 

10 

10 

5 

0 

RPN 

18 

28 

21 

13 

1 

7 

Competencies addressing unstable health conditions 


Independent 

In consultation 

With direction 


1996 

2001 

1996 

2001 

1996 

2001 

LPN 

0 

0 

1 

6 

5 

9 

RN 

0 

0 

22 

41 

18 

15 

RPN 

12 

23 

25 

18 

3 

7 


* 65% or greater level of agreement 
Source: reference (1 ) 

Table 2: Shared and unique competencies for LPNs * 


Area of 
competency 

Unique 

With RNs 

With RPNs 

Common to LPN, 
RN, RPN 


1996 

2001 

1996 

2001 

1996 

2001 

1996 

2001 

All competencies 

1 

0 

6 

11 

2 

0 

147 

209 


1996 

2001 

1996 

2001 

1996 

2001 

1996 

2001 

Level of autonomy 

0 

0 

6 

10 

1 

0 

96 

140 


1996 

2001 

1996 

2001 

1996 

2001 

1996 

2001 

Stable health 
conditions 

0 

0 

5 

8 

0 

0 

34 

42 


1996 

2001 

1996 

2001 

1996 

2001 

1996 

2001 

Unstable health 
conditions 

0 

0 

0 

1 

0 

0 

6 

14 


*65% or greater level of agreement 
Source: reference 


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Subsequent information on competencies 

It is understood from a number of personal communications that numbers of 
competencies have increased for all nursing categories over the last five years. 
However, no comparative data corresponding to the material in the National 
Nursing Competency Report have been located. A summary of entry to practice 
competencies for RNs in the province has been published by the AARN and a 
competency profile for LPNs by the CLPNA (3), and a draft competency profile 
for RPNs by the RPNAA. 

Information from British Columbia (BC) 

The report Licensed practical nurses and care aides in BC. Research on roles and 
utilization contains useful material on LPN competencies. It points out 
(Chapter 2) that ''One of the interesting aspects of the competency studies is the 
high number of competencies shared among the nursing groups - LPNs, RNs 
and RPNs. For example, all three groups share assessment competencies, though 
the depth and breadth of the knowledge, skills and judgement used to assess 
clients varies in the three groups. . . . The level of LPN independence becomes 
important in situations where competencies are shared. LPNs entering practice 
are prepared to care for individuals who have well defined health challenges and 
predictable health outcomes. LPNs are also prepared to work in partnership 
with other members of the nursing team to provide care for clients with less 
predicable outcomes and/or increasingly acute conditions." 

Also, (p 295) "Competencies are identified and organized in a number of ways, 
depending on the purpose and use for which the competencies are intended. For 
example, competencies developed from an occupational analysis are usually 
present oriented, detailed and context-specific. 

On the other hand, competencies developed to guide curriculum development 
for entry level practice are usually more future oriented, fairly broad, and have 
less emphasis on a particular context." 

The report includes details of a survey of LPN skill utilization in BC. Tlie sur\^ey 
was mailed to 33 acute care and 29 continuing care facilities. All acute care sites 
were sent three copies of the survey: one for a medical miit, one for a surgical 
unit, and one for an extended care unit. In total, 70 sur\^eys from 59 facilities 
were returned, a response rate of 75%. The College of LPNs confirmed that all of 
the entry level competencies in the survey are within the scope of practice and 
reflect the current standards of LPNs in BC. The BC report includes considerable 
detail on responses to questions on the responsibilities of LPNs in the province. 
This seems a helpful reference on current roles of LPNs in a Canadian health care 


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system and covers information obtained on patient assessment, medication 
management, wound management, airway management, elimination 
management, infusion management, and communication. 

Results of the competencies survey indicate an under-utilization in some 
competencies - for example, administering oral medications, dressing simple 
wounds, and performing certain assessments - and a higher utilization in others 
- for example, administering topical medications and assisting with deep 
breathing and coughing. 

The Scope of Practice Review by the BC Health Professions Council includes 
discussion of the LPN, RN and RPN groups in the province and identifies 
common and unique competencies for them A summary of the CounciTs 
recommendations is given in Appendix B. 

Specific training programs 

Some reports of training programs for specific tasks that involved LPNs were 
identified in the literature review. 

Wise reported a study of training for intravenous (IV) therapy preparation for 
LPNs and RNs in Kentucky, which used a self report Likert scale survey. They 
found that 24.5% more post licensure prepared nurses than pre licensure 
prepared nurses perceived that they were adequately prepared to perform IV 
therapy. They suggest the finding supports the use of LPNs trained in post 
licensure courses. A weakness of this study was the low response rate to the 
questionnaires. 

An overview of United States (US) practice by Roth concludes that in the scope 
of intravenous nursing practice, LPNs and LVNs can competently perform 
specific IV therapy procedures after successfully completing a well-structured FV 
nursing continuing education process. This article provides an overview of the 
various processes that need to be employed to ensure FV nursing competency of 
LPNs and LVNs before effectively integrating them into the specialty of FV 
nursing. This seems in contrast to the conclusions of Kutner et al. in a US 
study of 19 nursing homes, where provision of FV therapy was the most 
frequently identified measure to prevent hospital admission and "'RNs are 
necessary for FV therapy". 

A study by Ringerman and Ventura at a community hospital in southern 
California found that 55% of tasks for critically ill patients could be delegated to 
LVNs when working in partnership with an experienced RN. A training 
program is described. After they had completed this program, nine LVNs began 
working with a RN. Each team of critical care partners cared for a caseload of 


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four patients per shift. Outcomes pre-and post-implementation were unchanged 
except that patient and physician satisfaction increased, nurse satisfaction 
decreased, and labour costs per case dropped by 18%. 

A US study by O'CoiTnell et al. describes a nursing home education program 
on metered - dose inlialer technique that was offered to RNs, LPNs, and TM As. 
The program significantly improved inlialer technique for all staff, but retention 
of material decreased as early as two months after education, so that the program 
should be repeated frequently. 

Roles of LPNs in Canada 

The report on licensed practical nurses and care aides in BC provides examples 
of the use of LPNs in that province and elsewhere in Canada 

Within BC, facilities employing LPNs included acute care (40 out of 44), acute 
with extended care (17 of 24), intermediate care (20 of 77), stand alone extended 
care (10 of 28) and multi-level care (8 of 18). 

In the acute care facilities surveyed, including acute with extended care units, 
LPNs were most commonly used on medical, surgical, cmd extended care units. 
The highest level of utilization (83% of facilities) of LPNs was on medical units. 
On surgical and extended care units, utilization of LPNs was 74% and 71% 
respectively. Other units most likely to employ LPNs included: rehabilitation, 
palliative/ oncology, geriatric, pediatric, subacute/ transitional, and operating 
room/ day surgery. Utilization of LPNs on these units ranged from 31% to 57%. 
Overall, the ratio of RNs to LPNs was 6.4:1 and the ratio of RNs plus RPNs to 
LPNs was 6.9:1. 

Considerable detail on deployment of nursing staff in Canada is given in Volume 
TV of the Nursing Workforce Study published by the Centre for Health Services 
and Policy Research, University of British Columbia There is a threefold 
difference in the deployment of LPNs from East to West. 

The report on licensed practical nurses and care aides in BC cites the publication 
by Dussault et al. which reported that the average ratio of RNs to LPNs in 
Canada is 3:1 and that this ratio varies across Canada from 2:1 in Newfoundland 
to 5.4:1 in BC. The ratio for Alberta was 4.5:1. The estimates are based on 
statistics collected by nursing regulatory bodies for the Canadian Institute for 
Health Information. 

Chapter 7 of the report on licensed practical nurses and care aides in BC 
includes profiles of the LPN role in three acute care hospitals and four 
continuing care facilities in different provinces. One profile covers a pilot project 


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that started in January 1999 at a medical unit in the Royal Alexandra Hospital, 
Edmonton. Staffing was determined by patient acuity, with patients' needs 
matched with nurses' competencies (Days: three LPNs and three RNs; evenings: 
two LPNs and three RNs; nights: one LPN and two RNs). LPNs provided total 
patient care, including IV maintenance and medication administration. After one 
year, the project was considered a success as measured by patient and family 
feedback, job satisfaction from RNs and LPNs, and other outcome measures. The 
approach taken has been continued at the hospital and has now also been 
applied to surgical units. 

Three examples are given of emerging roles for LPNs and care aides in B.C. 
(p258). These include a LPN in the fast track emergency unit at a regional acute 
care facility, a LPN providing foot care to residents at a nursing home in a 
northern community, and a care aide working as a Total Care Worker in a 
nursing team at Vancouver General Hospital's psychogeriatric assessment unit. 

An earlier project at the Foothills Hospital, Calgary considered issues arising 
following changes in 1991 to introduce LPNs into active treatment areas A 
profile of the LPN's role was developed according to patient indicators and 
nursing activities, with observations on 22 LPNs. The high proportion of LPN 
assignments to Level III patients was seen as a possible concern as "their 
educational background does not prepare them for some aspects of patient care 
at this level of acuity." Some general points emerged and the project group 
made several recommendations: 

• The hospital must ensure consistency across all patient units to ensure 
LPNs can practice to the full extent of their scope and position 
descriptions. 

• Education must continue to ensure LPN's in service and learning needs 
are met. 

• Scope of practice on each unit should be examined to ensure LPNs work 
to the limit of their scope of practice without going beyond or under it. 

• The hospital needs to continuously clarify the supervisory roles of the RN 
to ensure that LPNs are not working autonomously. 

• Careful management of change will be necessary, recognising sensitivities 
and need for consultation and appropriate education. 

Since that time there have been significant changes to the education and 
competencies of LPNs in Alberta following implementation of recommendations 
made in 1994 by the Licensed Practical Nurses Educational Standards Advisory 


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Committee to the Health Disciplines Board and recognized in the pro\dsions 
of the Health Professional Act. 

Skill Mix of Nursing Staff and Patient Outcomes 

Only issues related to staff/skill mix are considered here - several studies that 
were reviewed also addressed other issues. Only those studies that in some 
fashion considered quality of care issues were included. No specific definition of 
patient outcomes was adopted for this review. Various measures of outcome 
were used in individual studies. 

Very limited information has been located that informs Objectives 2 and 3 of the 
project. There appears to be a continuing shortage of credible studies that 
address skill mix of nursing staff in relation to outcomes. Some of the more 
rigorous studies are summarised in Table 3, though a number of these were 
considered in an earlier review by the AARN tis). No study focuses on the points 
of separation along the continuum of care. 

The AARN reviews 

The literature review on nursing skill mix and patient/ client outcomes published 
by the AARN provides a useful introduction xhe review noted that literature 
addressing this area was not extensive. The review identified 58 publications 
through a database search of which only 10 met inclusion criteria. Not all of 
these were directly relevant to the skill mix issues being explored in the present 
paper. In two of the studies lower mortality rates were observed in hospitals 
with a greater proportion of RNs to other nursing staff, but there were a number 
of other significant variables The AARN review mentions that . .it is 

difficult to conclude that staffing mix alone has a direct relationship to patient 
mortality. We can, however, confidently state that positive interdisciplinary 
relationships, effective communication and coordination among team members 
and professional autonomy have a distinct effect on patient mortaliW" (^5) 

The review draws attention to the relationship between the staffing le\’els and 
skill mix with acuity, complications, and length of hospital stay. For the 
purposes of the present paper, a significant study was that by Carr-Hill et al. 

In 15 acute medical or surgical wards at seven hospital sites in the UK they found 
that '"Quality of care was better with the more qualified nurse. Tliis variation 
was reduced when more qualified staff worked in collaboration with less 
qualified providers". A further analysis by tliis group indicated that qualiW of 
nursing care improved as the ratio of qualified and further trained staff 


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increased, the authors noting that grade was being used as a proxy for skill 
Costs also increased with the quality of nursing care in this study. 

The study by Munroe of nursing home care in California found that ''The 
hypothesis that nursing homes with a higher ratio of RN hours to LVN hours per 
resident day will demonstrate a higher quality of care was supported, though 
modestly, by this investigation". On the other hand, the study by Pearson et 
al. (21) of Australian nursing homes found that there was no relationship between 
the level and type of training of nursing home staff and resident outcomes. 
However, there was a significant relationship between participation in service 
training and most outcomes. 

Papers identified in the 1997 literature update published by the AARN ( 22 ) had a 
focus on cost issues. Reference is made to two United States publications that 
reviewed earlier literature and drew attention to associations between increased 
skill mix and nursing staff numbers and patient outcomes (23, 24) 

Subsequent literature 

A recent study at 19 teaching hospitals in Ontario indicated that a higher 
proportion of registered nurses in inpatient medical /surgical and obstetrical 
units was associated with better health and quality outcomes for patients at the 
time of hospital discharge and with lower rates of medication errors and wound 
infections (25). Nursing staff mix was found to be a significant predictor of 
patients' functional independence, pain, social functioning, and satisfaction with 
obstetrical care at the time of discharge, after controlling for case mix, baseline 
health status, patient age, gender, and complexity of illness. The effect of staff 
mix on patient outcomes was not evident at the time of the 6 week follow-up. 

Anderson et al. (26) considered patterns of resource allocation that related to 
resident outcomes for all nursing homes in Texas. Secondary data were obtained 
from the state Department of Health Services and 11 items selected that reflected 
outcomes of care. Comparing pattern scores by resident outcome groups, for 
those with the best and worst average outcomes, differences in staffing patterns 
for RNs, LVNs and nursing aides were statistically non-significant. 

Comparing groups with the greatest and least improvement in outcomes, 
differences in staffing patterns when all three staff groups were considered was 
again non-significant. If only RNs and LVNs were included in the analysis, then 
nursing homes with the greatest improvement in resident outcomes allocated 
more RN staff than those with the least improvement in outcomes. There was no 
significant difference in the level at which LVNs were allocated. Nursing homes 
in the group with highest levels of RN staffing had generally greater 


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improvement in outcomes than those with lowest levels of RNs, though this was 
not so for four of the 11 outcome measures. 

The study by Blegen et al. (2^) considered data from 1992 - 93 for 42 nursing care 
units at a large university hospital in the United States. Tliere were 1,074 FTE 
nursing staff members of whom 832 were RNs. Data came from hospital records 
and included staffing, adverse outcomes, patient complaints and acuity. Nursing 
system acuity data were used to control for case severity. 

The proportion of hours of care by RNs was inversely related to medication 
errors, decubiti rates and complaints from patients or their families. Similar 
relationships with urinary and respiratory infections and with death were also 
suggested by the data, though statistical significance was not reached. Blegen et 
al. (27) found these effects were present up to a staff mix of 87.5% RNs. 
Relationship between staffing levels and patient falls was not clear. Total hours 
of patient care, delivered by RNs, LPNs, and NAs, were associated with higher 
rates of decubiti, complaints and death, but also with acuity. 

These authors suggest that their results lend support to earlier recommendations 
by So vie (28) of at least 70% RNs for medical /surgical units and 80% RNs for 
intensive and intermediate care units. 

Gould et al. (^2) briefly describe training and use of NAs in a surgical nursing 
division in Iowa to enable optimal utilisation of RNs through the two groups 
working as a team. The process included identification of tasks, consultation 
with staff nurses and a survey of all staff (RNs, NAs, LPNs, nursing unit clerks), 
three months after the changes were implemented. The authors give details of 
reduction in overtime following the change and a decrease in a number of 
concerns about quality of care, including documentation. It is not clear whether 
overall patient care hours increased. 

Other studies 

A Swedish study compared nursing personnel's perceptions of urinary 
incontinence care routines and patient observations in three different health units 
(health care centre, a nursing home and a geriatric clinic). The analyses included 
variances between the different categories of nursing persoimel (nurses, assistant 
nurses and auxiliary nurses) and care units. Tliere were no significant 
differences between personnel groups and care units in respect to care routines, 
but registered nurses answered more correctly than the other nursing personnel 
on the questionnaire about patient observations (2^). There were no significant 
differences between the care units in regards to patient observations. 


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Peruzzi et al. give a lengthy account of redesign of nurse staffing at a 
community hospital in Albany, New York. Changes involved increased use of 
nurse assistants and 'support service associates'. The changes were considered 
to have been associated with improved or unchanged quality and satisfaction. 
Changes to duties and organisation of LPNs are not clear. 

In a study that pointed to the significance of staffing levels for other types of 
health care worker, Robertson and Hassan analysed United States hospital 
data from the early 1990s to explore relationships between skill mix, staff 
resources, and mortality from chronic obstructive pulmonary disease. Results 
for skill mix were inconclusive and the only group whose staff intensity was 
positively associated with better outcomes for this patient group was respiratory 
physicians, therapists and technicians. Absence of significant negative effects of 
staffing intensities in nursing (both RNs and LPNs were considered) was taken 
to mean that in the hospitals that were studied staffing levels were above the 
critical level for staffing intensity that would have affected patient outcomes. 


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Table 3: Selected studies that considered skill mix and patient outcomes 


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Alberta Heritage Foundation tor Medical Research 
Health Technology Assessment 


Table 3: Selected studies that considered skill mix and patient outcomes (cont’d) 


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Alberta Heritage Foundation for Medical Research 
Health Technology Assessment 


Table 3: Selected studies that considered skill mix and patient outcomes (cont’d) 



Alberta Heritage Foundation tor Medical Research 
Health Technology Assessment 


Nursing Skill Mix and Health Care Outcomes 


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Alberta Heritage Foundation for Medical Research 
Health Technology Assessment 


Nursing Skill Mix and Health Care Outcomes 


Other Issues 

Several studies have found an inverse relationship between nurse staffing le\'els 
and adverse events in hospitals. Findings seem more commonly to be in terms of 
overall nurse levels rather than in relation to differences in skill mix. Ko\'ner and 
Gergen (^6)^ in a study of 589 acute care hospitals in the United States, found a 
significant inverse relationship between RNs per adjusted inpatient day and 
urinary tract infection and pneumonia after surgery. There were less robust 
relationships between numbers of RNs and post surgical thrombosis or 
pulmonary compromise. However, they note that it is possible that high o\^erall 
staffing levels are inversely related to adverse events, rather than to levels for a 
particular type of health worker such as RNs. Hartz et al. (3/), in a study of 3,100 
United States hospitals, found that lower mortality rates were associated with the 
percentage of nurses who were RNs. Flood and Diers in a study at a 
community hospital in northeastern United States, found improved outcomes 
(length of stay) and decreased costs when two general medical units were 
adequately staffed (staffing mix for both budgeted at 10.7 RNs, one LPN, and six 
nurse aides). 

In a study involving 276 nurses in a large hospital in Northern Ireland, grade of 
nursing was unrelated to job stress and outcome health variables, including work 
satisfaction (39). xhe authors cite earlier studies indicating RNs experienced more 
stress than non-registered nurses, with a UK study suggesting this pattern was 
only significant for stress associated with organisational features. 

Anderson and McDaniel in a United States study on nursing homes found 
that RN participation in organisational decision making was related to 
improvements in patient outcomes, but did not include skill mix in their analvsis. 

Daykin and Clarke have used qualitative interview data to illustrate tensions 
among nurses and health care assistants in English hospital wards following 
changes to work organisation in the National Health Ser\dce. Importmice of 
interaction between physicians and nurses has been noted in a number of 
studies, though these have not been considered for the purposes of this re\aew. 

Anthony et al. (-^ 2 ) discuss a national survey of licensed nurses in the United 
States that describes factors associated with patient outcomes when nursing 
activities are delegated to unlicensed assistive persomiel (UAP). Licensed 
nurses' overall experience and UAP's experience in the work setting were 
associated with more positive events. When the outcome of the delegated 
activity was determined by routine observation, more positive events occurred. 
When there was no direct supervision of the UAP, more negative events 


Alberta Heritage Foundation for Medical Research 17 

Health Technology Assessment 


Nursing Skill Mix and Health Care Outcomes 


occurred. This survey had a poor response rate and there were insufficient data 
to undertake a comparative analysis of delegation and supervision of UAP by 
RNs and LPNs. 

Implications for RHAs in Changing Nursing Skill Mix 

This review suggests that there is at present rather little in the literature to assist 
the CHR in their decisions on how to manage expected changes to the nursing 
workforce. It was hoped that the recent literature would provide examples of 
empirical studies that addressed skill mix of LPNs and other nursing staff in 
relation to health outcomes and areas of work. This has not proved to be the case 
and the papers that have been reviewed can do little more than provide general 
guidance. An important consideration for the CHR is where there is separation 
along the continuum of delivery of patient care between the competencies of the 
three nursing groups. No study was located that addressed this issue. 

Buerhaus and Needleman ('^3) have summarized several current United States 
projects which include consideration of nurse staffing and patient outcomes 
potentially sensitive to nursing, which may provide information pertinent to the 
present project. 

Those studies that are available tend to have only marginal relevance to practical 
issues that will be faced by RHAs and some have methodological limitations. 
Some of the limitations have been considered by McKenna and include use of 
small samples and non-representative sampling techniques In general, there 
is a need for caution regarding the generalizability of research findings in this 
area. There is a need to recognise the importance of context and practice settings 
and also the influence of non-nursing staff on outcomes. Staffing models may 
vary from health region to health region and be influenced by such factors as the 
health services delivered, patient/ client loads and acuity levels. Also, patients' 
needs change over time so that changes in nursing skill mixes may need to be 
time and case mix sensitive. Practice patterns in Canada will differ from those in 
the US and some other countries, so that results from studies conducted 
elsewhere may need to be interpreted with caution. 

The material available on competencies provides useful broad guidance, though 
there is limited information on the current situation and the information on entry 
to practice competencies needs to be kept in context. Material on the use of LPNs 
in other Canadian provinces is of interest and, while no related health outcome 
measures have been obtained, clearly much lower RNrLPN and RPNiLPN ratios 
than those in Alberta are a reality for other parts of the country. Also, it seems 
worth considering points made by Hegney et al. in their discussion on activities 


Alberta Heritage Foundation for Medical Research 
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18 


Nursing Skill Mix and Health Care Outcomes 


of rural nurses in Australia Tliey state that ''Tire rural nurse, registered, 
enrolled or assistant appears to extend their role both up and down the health 
care hierarchy to 'fill the gaps' in the delivery of health care due to the 
unavailability of other cost effective services." They also suggest that both 
registered and enrolled nurses who work in different sized health ser\dces 
require a different skill mix. 

The way forward for RHAs may be to continue to introduce additional LPN 
staffing in specific areas with appropriate evaluation to 'test the water'. Such a 
process would require full consultation and involvement of nursing and other 
health care professionals, appropriate in-service training, monitoring and 
evaluation of nursing-sensitive health outcomes. The review by Edwardson and 
Giovanetti concluded that research which focuses on costs and outcomes of 
care, as opposed to methods for staffing predictions, will best inform decisions 
about skill mix and intensity of required nursing care. It may be that the 
assessment process would need to be continuous as changes were made to 
different areas, as generalizability of findings could be limited. 

A number of general frameworks and instruments have been suggested which 
would be helpful in considering how to develop appropriate local level 
assessment to inform decisions on the role of nursing staff. For example, the 
need for use of nursing - sensitive outcomes and some general approaches to 
measuring these are discussed by Oermaim and Huber From the indications 
obtained in the present review, local assessment to inform local decisions, rather 
than reliance on findings and recommendations in the available literature, would 
seem to be the way to go. 


Alberta Heritage Foundation for Medical Research 
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Appendices 



Nursing Skill Mix and Health Care Outcomes 


Appendix A: Literature Review 

Details of the literature search are shown in the following table. 

Inclusion criteria: Any studies describing Canadian nursing competencies that 
included consideration of LPNs. Any scientifically credible empirical study that 
considered the relationship between skill mix and patient outcomes. 

Exclusion criteria: Studies on skill mix that did not consider outcomes issues; 
studies that considered only cost issues as outcomes; general reviews without 
empirical data. 


Database Searched 

Subject Headings/Textwords Combinations 

MEDLINE (Ovid) 

1991 -May 2001 

1 

Group A terms: 

*nurses OR exp ^nursing, practical OR exp ^education, 
nursing, baccalaureate OR exp "^licensure, nursing OR exp 
^nursing 

For Project Objective #1 : 

Group A terms 
AND 

Exp ^clinical competence OR exp ^professional 
competence 

AND 

comparative study OR Compar$.mp. 

For Project Objective #2 

Group A terms 

AND 

exp ^personnel staffing and scheduling OR 

Skill mix.mp. OR staff$ ratio$.mp. OR staff$ level$.mp. OR rn 
mix.mp. 

AND 

outcome$.mp. 

Note: Bolded are MeSH in this database 


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Database Searched 

Subject Headings/Textwords Combinations 

PubMed 
1991 -July 2001 

nurse OR nurses OR nursing 
AND 

Skill mix OR competenc* 
AND 

patient* AND outcome* 

EMBASE (Ovid) 
1991- April 2001 

Exp *nurse 
AND 

Exp *competence OR competenc?. mp. OR skill mix.mp. OR 
staff$ ratios. mp. OR staffS levelS.mp. OR exp *treatment 
outcome OR exp *outcomes research 

Best Evidence (Ovid) 
1991 -Feb 2001 

NursS.mp. AND competencS.mp. OR skillS.mp. 

HTA 

Nurs* AND (skill* OR competenc*) 

Note: No relevant retrieval in these databases 

EED 

DARE 

Cochrane Database of 
Systematic Reviews 
2001 Issue 2 

ECRI website 

Database Searched 

Subject Headings (Bold) /Textwords Combinations 

HealthSTAR (Ovid) 
1991- Dec 2000 

Same as MEDLINE search, limit to non-medline 

CINAHL (Ovid) 
1991 -March 2001 

For Project Objective #1 : 

Exp * registered nurses OR exp *practical nurses 
AND 

Exp * education, competency-based OR exp *clinical 
competence OR exp *professional competence OR exp 
*national vocational qualifications OR exp *competency 
assessment 

For Project Objective#2: 

Exp * registered nurses OR exp *practical nurses 
AND 

Exp *sklll mix OR staff$ ratio$.mp. OR staff$ level$.mp. 
AND 

*nursing outcomes OR *outcome assessment OR 
outcomes (health care) OR *treatment outcomes 

Psycinfo (Ovid) 
1991 -Feb 2001 

Exp *nurses 
AND 

exp *professional competence OR skill mix.mp. OR staff$ 
ratio$.mp. OR staff$ level$.mp. 


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Nursing Skill Mix and Health Care Outcomes 


Database Searched 

Subject Headings/Textwords Combinations 

InfoTrac Health Reference 

Nurs? 

Center-Academic 

AND 

1991-July 17, 2001 

(skill mix OR skill-mix) 

CMA Practice Guidelines- 

Nurse OR nurses 

CPG Infobase 
(July 12, 2001) 

No relevant retrieval 

National Guideline 

Nurs* AND (competenc* OR skill mix) 

Clearinghouse 
(July 12, 2001) 

No relevant retrieval 

WWW 

Browsing Alberta Association of Registered Nurses and 
Canadian Nursing Association websites to look for competence 
related publications 

Other material 

Publications supplied by AARN librarian. 


■ Date Limits: 1991-2001 see individual database for specific months 

■ Publication type limit to: no limit 


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Nursing Skill Mix and Health Care Outcomes 


Appendix B: Excerpts from the BC Health Professions 
Council Scope of Practice Review <5) 

Shared scope and reserved acts 

Scope of practice statements describe in general terms what a profession does 
and how it does it. On the other hand, reserved acts, defined as those "tasks and 
services involving a significant risk of harm," need to be restricted, and may only 
be performed by professions to whom they are, on a non-exclusive basis, 
assigned, and so long as those performing them are acting within the scope of 
practice of their profession. 

The Council developed a list of such activities, the Reserved Acts List , and in its 
review of each profession determined which of the reserved acts it was qualified, 
as a profession, to perform. 

Nurses, licensed practical 

Scope of practice 

The practice of nursing by licensed practical nurses is the provision of health care 
for the promotion, maintenance and restoration of health; and the prevention, 
treatment and palliation of illness and injury, including assessment of health 
status and implementation of interventions. 

Reserved acts 

2(e) For the purpose of assessing an individual or assisting an individual with 
activities of daily living, performing the physically invasive or physically 
manipulative act of putting an instrument, hand or finger(s) 

i. into the external ear canal, including applying pressurized air or 
water, for the purpose of cleaning patients' external ear canal, taking 
their tympanic temperature and using an otoscope to examine 
cerumen build up; 

V. beyond the labia majora, but excluding the insertion of intrauterine 
devices, for the purpose of performing hygiene measures and 
washing beyond the labia majora to the urethral and vaginal orifice; 

vi.beyond the anal verge, for the purpose of performing rectal checks on 
patients whose assessment warrants this intervention. 


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Nursing Skill Mix and Health Care Outcomes 


Reserved acts to be performed only if the act is ordered by a health 
professional who is authorized by legislation to perform the act: 

2. Performing the following physically invasive or physically manipulative 
acts: 

(a) procedures on tissue below the dermis or below the surface of a mucous 
membrane; 

(d) administering a substance, other than a drug, by subcutaneous injection, 
inhalation, irrigation or instillation; 

(e) putting an instrument, hand or finger(s) 

i. into the external ear canal, but excluding cerumen 

management; iv. beyond the opening of the urethra; v. beyond 
the labia majora, but excluding the insertion of intrauterine 
devices; vi. beyond the anal verge; or vii. into an artificial 
opening into the body. 

5(a) Administering orally or by subcutaneous injection a drug listed in Schedule 
I or II of the Pharmacists, Pharmacy Op'>erations and Drug Scheduling Act. 

Nurses, registered 

Scope of practice 

The practice of nursing by registered nurses is the provision of health care for the 
promotion, maintenance and restoration of health; the prevention, treatment and 
palliation of illness and injury, primarily by assessment of health status, plamiing 
and implementation of interventions; and co-ordination of health services. 

Reserved acts 

1. Performing a nursing diagnosis by making a clinical judgment of the 

patient's mental and physical condition that can be ameliorated or resolved 
by appropriate interventions of the nurse or nursing team to achieve 
outcomes for which the nurse is accountable. 

2(a) (i) For the purpose of wound care, performing the following physically 

invasive or physically manipulative act of procedures on tissue below the 
dermis or below the surface of the mucous membrane: 

• cleansing, 

• soaking, 

• irrigating, 

• probing, 

• debriding. 


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Nursing Skill Mix and Health Care Outcomes 


• packing, 

• dressing. 

2(a)(ii)For the purpose of establishing peripheral intravenous access and 

maintaining patency using a solution of normal saline (0.9 per cent), 
performing the physically invasive or physically manipulative act of 
venipuncture. 

2(e) For the purpose of assessing an individual or assisting an individual with 
activities of daily living, performing the physically invasive or physically 
manipulative act of putting an instrument, hand or finger(s) 

i. into the external ear canal, including applying pressurized air or 
water; 

ii. beyond the point in the nasal passages where they normally narrow; 

iii. beyond the pharynx; 

iv. beyond the opening of the urethra; 

V. beyond the labia majora; 

vi. beyond the anal verge; or 

vii. into an artificial opening into the body. 

5(a) Administering or compounding a drug listed in Schedule II of the 
Pharmacists, Pharmacy Operations and Drug Scheduling Act. 

For the purposes of this reserved act, "compounding" means mixing 
ingredients, at least one of which is a drug listed in Schedule II of the 
Pharmacists, Pharmacy Operations and Drug Scheduling Act. 

Reserved acts to be performed only if the act is ordered by a health 
professional who is authorized by legislation to perform the act: 

2(a) For purposes other than wound care, performing the physically invasive or 
physically manipulative act of procedures on tissue below the dermis, 
below the surface of a mucous membrane, and in or below the surface of the 
cornea. 

2(d) Performing the physically invasive act of administering a substance, other 
than a drug, by injection or inhalation, except as provided in reserved act 
2(a)(ii). 

2(e) For the purpose of treatment, performing the physically invasive or 
physically manipulative act of putting an instrument, hand or finger(s) 

i. into the external ear canal, including applying pressurized air or water; 

ii. beyond the point in the nasal passages where they normally narrow; 


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Nursing Skill Mix and Health Care Outcomes 


iii. beyond the pharynx; 

iv. beyond the opening of the urethra; 

V. beyond the labia majora; 

vi. beyond the anal verge; or 

vii. into an artificial opening into the body. 

4. Applying a hazardous form of energy, including diagnostic ultrasound and 
X-ray. 

5(a) Administering or compounding by any means a drug listed in Schedule 1 of 
the Pharmacists, Pharmacy Op^erations and Drug Scheduling Act. 

For the purposes of this reserved act, "compounding" means mixing 
ingredients, at least one of which is a drug listed in Schedule I of the 
Pharmacists, Pharmacy Operations and Drug Scheduling Act. 

5(b) Designing, compounding or dispensing therapeutic diets where nutrition is 
administered through enteral or parenteral means. 

For the purposes of this reserved act, the following definitions shall apply: 

"designing": the selection of appropriate ingredients for enteral or 
parenteral nutrition. 

"compounding": mixing ingredients for enteral or parenteral nutrition. 

"dispensing": filling a prescription for enteral or parenteral nutrition. 

7. Allergy challenge testing or allergy desensitizing treatment involving 
injection, scratch tests or inhalation, and allergy challenge testing by any 
means with respect to a patient who has had a previous anaphylactic 
reaction. 

Nurses, registered psychiatric 

Scope of practice 

The practice of nursing by registered psychiatric nurses is the provision of health 
care for the promotion, maintenance, restoration and palliation, primarily of 
mental and emotional health and associated physical conditions by assessment of 
mental and physical health, planning and implementation of interventions and 
co-ordination of health services. 

Reserved acts 

1. Performing a nursing diagnosis by making a clinical judgment of the 
patient's mental and physical condition that can be ameliorated or 
resolved by appropriate interventions of the nurse or nursing team to 
achieve outcomes for which the nurse is accountable. 


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Nursing Skill Mix and Health Care Outcomes 


2(a)(1) For the purpose of wound care, performing the following physically 

invasive or physically manipulative act of procedures on tissue below the 
dermis or below the surface of the mucous membrane: 

• cleansing, 

• soaking, 

• irrigating, 

• probing, 

• debriding, 

• packing, 

• dressing. 

2(a)(ii)For the purpose of establishing peripheral intravenous access and 

maintaining patency using a solution of normal saline (0.9 per cent), 
performing the physically invasive or physically manipulative act of 
venipuncture. 

2(e) For the purpose of assessing an individual or assisting an individual with 
activities of daily living, performing the physically invasive or physically 
manipulative act of putting an instrument, hand or finger(s) 

i. into the external ear canal, including applying pressurized air or water; 

ii. beyond the point in the nasal passages where they normally narrow; 

iii. beyond the pharynx; 

iv. beyond the opening of the urethra; 

V. beyond the labia majora; 

vi. beyond the anal verge; or 

vii. into an artificial opening into the body. 

5(a) Administering or compounding a drug listed in Schedule II of the 
Pharmacists, Pharmacy Operations and Drug Scheduling Act. 

For the purposes of this reserved act, "compounding" means mixing 
ingredients, at least one of which is a drug listed in Schedule II of the 
Pharmacists, Pharmacy Operations and Drug Scheduling Act. 

Reserved acts to be performed only if the act is ordered by a health 
professional who is authorized by legislation to perform the act: 

2(a) For purposes other than wound care, performing the physically invasive 
or physically manipulative act of procedures on tissue below the dermis, 
below the surface of a mucous membrane and in or below the surface of 
the cornea. 


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Nursing Skill Mix and Health Care Outcomes 


2(d) Performing the physically invasive act of administering a substance, other 
than a drug, by injection or inlialation, except as provided in reserved act 
2(a)(ii). 

2(e) For the purpose of treatment, performing the physically invasive or 

physically manipulative act of putting an instrument, hand or finger(s) 

i. into the external ear canal, including applying pressurized air or water; 

ii. beyond the point in the nasal passages where they normally narrow; 
hi. beyond the pharynx; 

iv. beyond the opening of the urethra; 

V. beyond the labia majora; 

vi. beyond the anal verge; or 

vii. into an artificial opening into the body. 

4. Applying a hazardous form of energy, including diagnostic ultrasound 
and X-ray. 

5(a) Administering or compounding by any means a drug listed in Schedule I 
of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. 

For the purposes of this reserved act, "compounding" means mixing 
ingredients, at least one of which is a drug listed in Schedule I of the 
Pharmacists, Pharmacy Operations and Drug Scheduling Act. 

5(b) Designing, compounding or dispensing therapeutic diets where nutrition 
is administered through enteral or parenteral means. 

For the purposes of this reserved act, the following definitions shall 
apply: 

"designing": the selection of appropriate ingredients for enteral or 
parenteral nutrition. 

"compounding": mixing ingredients for enteral or parenteral nutrition, 
"dispensing": filling a prescription for enteral or parenteral nutrition. 


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Nursing Skill Mix and Health care Outcomes 


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