Impact of a high proportion of unskilled personnel on quality of care and patient safety in the healthcare services: a systematic review
We searched for studies that evaluate the effects on quality of care and patient safety of a high proportion of unskilled personnel working with patients and the effects of changes in skill mix.
- Issued/Revised: 03.2017
- By: Folkehelseinstituttet
In Norway around 25% of personnel working in the municipal health and care services lack a relevant health-related education (i.e. unskilled), while at the same time the care need of patients in the community is increasing. We know little about how this affects the quality of services and the safety of patients. In addition, we know little about the consequences of changes in skill mix, e.g. when higher qualified personnel are replaced with personnel with lower qualifications. With skill mix we mean the composition of the various categories of nursing staff providing direct patient care.
With the aim to summarise the evidence in the field in a systematic review, we searched for studies that evaluate the effects on quality of care and patient safety of a high proportion of unskilled personnel working directly with patients and the effects of changes in skill mix.
- We found no studies that evaluated the impact on quality of care and patient safety of a high proportion of unskilled personnel working in direct patient care.
- Nor did we find any eligible studies that evaluated the impact on quality of care and patient safety of a change in skill mix.
This review highlights the lack of high quality evidence from studies with robust study designs, on this important and current research topic.
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Nurse staffing, i.e. the number of nurses, nurse skill mix, and the experience and competence of nurses, are all factors of great importance to quality of care and patient safety. Optimally, staffing should match the care needs of different patient populations, to ensure that appropriate and safe care is delivered to all people, whether in acute hospitals or in nursing homes.
There is some evidence from systematic reviews (mostly uncontrolled data) that lower nurse staffing (density) is related (correlated) to more adverse patient outcomes, although not all systematic reviews report consistent relationships. It is however less clear how various skill mix levels relate to the quality of care and patient safety, and very little is known about the effects of unskilled personnel working in direct patient care. There is however a shortage of nurses in Norway, as well as in the rest of the world, and to recruit a sufficient number of qualified nurses and healthcare workers is difficult. This may increase the likelihood that more and more unskilled health workers are hired. This problem is greatest in the municipal health and care services.
In Norway, a large number of unskilled personnel work in the healthcare services, especially is this the case in the municipal health services. This is worrying partly because patients treated in municipal health services have an increasing need for care, but also because of the increasingly shorter hospital stay. It is however unknown how a high percentage of unskilled personnel affects the quality of care and patient safety in the healthcare services.
We have used McGillis Halls (2005) definition of skill mix which is "the combination of different categories of healthcare workers (read nursing personnel) that are employed for the provision of direct care to the patient." A richer skill mix level is when proportionally more registered (higher qualified) nurses work in a healthcare team, as compared to less rich (poorer) skill mix when the team consist of proportionally fewer registered nurses, and more licensed or unlicensed (assisting) personnel.
The aim of this systematic review was to answer the following two research questions:
1. What are the consequences on quality of care and patient safety of a higher/lower proportion unskilled personnel working in direct patient care in the healthcare services?
2. What are the consequences on quality of care and patient safety of different nurse skill mix, i.e. of a higher/lower proportion of highly skilled nurses working in direct patient care?
We conducted a systematic review in accordance with the Knowledge Centre in the Norwegian Institute of Public Health’s handbook. We searched nine electronic databases up to April 2016 for studies that evaluated the consequences of having unskilled personnel working in direct patient care, or the effects of different skill mix on quality of care and patient safety. We applied no time or language restrictions to the search.
Two people independently screened all titles and abstracts from the search, and reviewed possible eligible full texts for inclusion in the review against the inclusion criteria below:
All healthcare services (both hospitals and nursing homes, etc.)
Higher/lower proportion of personnel without a relevant health-education, or of highly skilled personnel (skill mix) in a team
Higher vs. lower proportion of personnel without a relevant health education or of highly skilled personnel (skill mix) in a healthcare team
Outcomes related to quality of care and patient safety e.g. information failure, malpractice, medication errors, abuse/violence and adverse outcomes (e.g. infections, pressure ulcers, falls, mortality) and patient satisfaction
Controlled studies (randomised and non-randomised), interrupted time series studies with at least three data-points before and three after the intervention, and controlled before-after studies with at least two intervention and two control sites
English, Norwegian, Swedish, Danish, German, Spanish and Icelandic. Languages not mastered by members of the project group would have been considered for inclusion if there were other employees at the Knowledge Center who had the necessary language skills.
We excluded studies that evaluated the effects of nurse intensity, i.e. studies that compared different nurse to patient ratios, as this was not within the scope of this review.
We solved disagreements through discussion between review authors.
We found no eligible studies that had used a robust study design to evaluate the impact on quality of care and patient safety of having a high proportion of personnel without a relevant health education working in direct patient care in the healthcare services, or studies that evaluated the impact of nursing skill mix that were eligible for inclusion in this systematic review.
Despite an extensive search of the literature, we found no controlled studies evaluating the consequences of a high proportion of unskilled personnel working in direct patient care in the healthcare services. Nor did we find any studies evaluating the consequences of changes in nurse skill mix.
The two relevant controlled trials that almost qualified for inclusion in this overview are neither of great help for resolving staffing problems nor improving decisions about safe staffing in the healthcare services. However, what these studies show is that it is possible to undertake evaluation studies in conjunction with organisational changes (e.g. skill mix changes) in the healthcare services. The question is why well-conducted controlled studies are so rarely used in this field of research.
The vast majority of studies on the research topic were cross-sectional and longitudinal studies that look for associations between skill mix and patient outcomes, but not causality. Our research question, however, is about how employing a high proportion of unskilled personnel to work in direct patient care (or changing skill mix to fewer registered nurses in the nursing team), affects quality of care and patient safety (effect).
In preparing this systematic review, we experienced challenges with assessing the eligibility of studies for inclusion in the review, as it was often difficult to know if the study evaluated skill mix or nursing intensity (i.e. number of nurses per patient).
This systematic review emphasizes the lack of evidence from high quality studies with robust designs in this area of research, and the importance of strengthening this field with well-conducted effect studies to gain knowledge about how best to ensure optimal care and patient safety.
We still do not know how a high proportion of unskilled personnel working in direct patient care, or changes in nurse skill mix affects quality of care and patient safety. This systematic review highlights the lack of evidence from controlled studies on this issue which is of great importance for the health services in Norway, and in other countries.