Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment

Duffield, Christine; Roche, Michael; Twigg, Di; Williams, Anne M.; Rowbotham, Sheila; Clarke, Sean P.

doi:10.1111/jocn.14632

Cited by 26 publications

(40 citation statements)

References 60 publications

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“…The increase in unregulated nursing support workers does not reduce unfinished nursing care. The replacement of nurses by these workers can lead to problems related to an increased workload of nurses due to task delegation and their subsequent supervision (Duffield et al, 2018). From the patient's perspective, unfinished nursing care is also perceived as a problem associated with adverse events, poor communication and poor patient satisfaction (Cho, Mark, Knafl, Chang, & Yoon, 2017).…”

Section: Human Resourcesmentioning

confidence: 99%

Good practices to reduce unfinished nursing care: An integrative review

et al. 2020

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Recent nursing investigations highlight that patient safety is compromised by unfinished nursing care. Unfinished nursing care can be described as an error of omission because the totality, or just part, of the care needed by the patient was not provided essentially due to time scarcity (Kalisch, Landstrom, & Hinshaw, 2009). As a result, nurses prioritize the essential care they need to provide to their patients, which may then lead to unfinished nursing care (Jones, Hamilton, & Murry, 2015). There is no consensus on which is the best terminology to define unfinished care. In literature, we may find expressions such as 'missed nursing care,' 'unfinished care,' 'care

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Section: Human Resourcesmentioning

confidence: 99%

Good practices to reduce unfinished nursing care: An integrative review

et al. 2020

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“…Interviewees from NA wards consistently reported heavy workloads on their wards, including a high number of challenging patients in their care. This perception was reflected in the nurse survey results: significantly more nurses on NA wards than on non-NA wards reported they had recently experienced physical assault, threat of assault, or emotional abuse, most often from patients (Duffield et al, 2018 Given the qualitative reports of heavy workloads and challenging patients, it is unsurprising that nurses on NA wards rated the ''Staffing and Resource Adequacy'' on their ward significantly lower than did nurses on non-NA wards (Duffield et al, 2018). These perceptions were confirmed by longitudinal administrative ward data that show nursing assistants were added to wards that had a lower skill mix (percent nursing hours provided by RNs) than wards where nursing assistants were not added (Twigg et al, 2016).…”

Section: Heavy Workloads and Challenging Patientsmentioning

confidence: 99%

Uncovering the Disconnect Between Nursing Workforce Policy Intentions, Implementation, and Outcomes: Lessons Learned From the Addition of a Nursing Assistant Role

Duffield

Twigg

Roche

et al. 2019

Policy, Politics, & Nursing Practice

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The use of nursing assistants has increased across health systems in the past 20 years, to alleviate licensed nurses' workload and to meet rising health care demands at lower costs. Evidence suggests that, when used as a substitute for licensed nurses, assistants are associated with poorer patient and nurse outcomes. Our multimethods study evaluated the impact of a policy to add nursing assistants to existing nurse staffing in Western Australia's public hospitals, on a range of outcomes. In this article, we draw the metainferences from previously published quantitative data and unpublished qualitative interview data. A longitudinal analysis of patient records found significantly higher rates adverse patient outcomes on wards that introduced nursing assistants compared with wards that did not. These findings are explained with ward-level data that show nursing assistants were added to wards with preexisting workload and staffing problems and that those problems persisted despite the additional resources. There were also problems integrating assistants into the nursing team, due to ad hoc role assignments and variability in assistants' knowledge and skills. The disconnect between policy intention and outcomes reflects a top-down approach to role implementation where assistants were presented as a solution to nurses' workload problems, without an understanding of the causes of those problems. We conclude that policy makers and managers must better understand individual care environments to ensure any new roles are properly tailored to patient and staff needs. Further, standardized training and accreditation for nursing assistant roles would reduce the supervisory burden on licensed nurses.

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“…For example, the substitution of RNs with less qualified, lower paid nursing assistants is justified on efficiency grounds: to allow RNs more time to focus on more complex clinical tasks (Kleinman & Saccomano, ; Spilsbury et al, ). However, the efficiency rationale for substitution is by no means proven since both hospital and ward‐level studies have associated lower skillmix with poorer patient and nurse outcomes (Aiken et al, ; Duffield et al, ; Twigg, Myers, Duffield, Giles, & Evans, ). Moreover, nursing assistants’ lower autonomy and skills means RNs must spend more time on communication and supervision (Duffield et al, ; Hasson, McKenna, & Keeney, ; Saccomano & Pinto‐Zipp, ).…”

Section: Introductionmentioning

confidence: 99%

“…However, the efficiency rationale for substitution is by no means proven since both hospital and ward‐level studies have associated lower skillmix with poorer patient and nurse outcomes (Aiken et al, ; Duffield et al, ; Twigg, Myers, Duffield, Giles, & Evans, ). Moreover, nursing assistants’ lower autonomy and skills means RNs must spend more time on communication and supervision (Duffield et al, ; Hasson, McKenna, & Keeney, ; Saccomano & Pinto‐Zipp, ). The strategy of using temporary staff (whether internal casual nurses or external agency nurses) to manage fluctuations in patient demand rather than permanently staffing spare capacity can place similar pressure on nursing workloads.…”

Section: Introductionmentioning

confidence: 99%

“…The combination of bed management strategies and the staffing decisions made to manage increased patient demand while improving efficiency have produced more complex and unstable ward environments that have an impact on nursing workload (Duffield et al, ; Swiger et al, ). The consequences of these working conditions for nurse, system and patient outcomes are significant and have been described elsewhere (Blay, Roche, Duffield, & Lu, ; Duffield et al, , ).…”

Section: Introductionmentioning

confidence: 99%

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Harnessing ward‐level administrative data and expert knowledge to improve staffing decisions: A multi‐method case study

Duffield

Roche

Wise

et al. 2019

Journal of Advanced Nursing

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Aim:The aim of this study was to investigate the impact of changes to bed configuration and patient mix on nurses' workload in a single ward.Design: Multi-method case study. Method:The study was undertaken in an acute 28-bed ward in a tertiary referral public hospital in Queensland, Australia. Ward-level administrative data were obtained for a 2-year period, 12 months before bed configuration changes in October 2015 and 12 months after. These data included patient activity (bed occupancy, transfers, length of stay and casemix) and nurse staffing (budgeted and actual staffing levels, employment status and skillmix). Semi-structured interviews were conducted with ward nurses (N = 17) to explore the impact of the bed configuration changes on their workload. Results:Administrative data showed that the bed configuration changes resulted in more complex and dependent patients, increased patient transfers and greater variability in casemix. The interview data found these changes to patient complexity and activity intensified workloads, which were further increased by staffing decisions that resulted in greater reliance on temporary staff. Conclusion:Hospitals already possess the data and expert knowledge needed to improve staffing and bed management decisions without the need for additional, costly workload systems. Impact: Determining appropriate nurse staffing in light of the complexities and variation of patient needs at the ward level remains a challenge. This study identified increases in patient complexity, dependency, variability and churn that increased workload. Staffing grew but hidden factors associated with temporary staffing and skillmix further intensified nurses' workload. Harnessing existing data and the expertise and experience of nursing unit managers (NUMs) would help staff wards more efficiently and effectively, providing reasonable workloads and appropriate skillmix that can enhance the safety and quality of patient care. To facilitate this, NUMs

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Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment

Cited by 26 publications

References 60 publications

Good practices to reduce unfinished nursing care: An integrative review

Good practices to reduce unfinished nursing care: An integrative review

Uncovering the Disconnect Between Nursing Workforce Policy Intentions, Implementation, and Outcomes: Lessons Learned From the Addition of a Nursing Assistant Role

Harnessing ward‐level administrative data and expert knowledge to improve staffing decisions: A multi‐method case study

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