Sometimes it’s essential to look to the past when facing current challenges in healthcare such as ongoing nursing workforce shortages. The first paper from Hall (1997) and then more recent from Jacob et al (2015) both highlight the challenges and changes when the skill mix in nursing is altered.

“Many emerging models appear to provide substitute workers for the Registred Nurse rather than complement the nursing role.”

Workforce Challenges Past & Present

• Nursing workforce shortages
• Rising health care costs
• Increasing life expectancy and chronic illness
• Global economics

Nurse Substitution

“The term substitution (in the context of the nursing workforce) means the deliberate and planned replacement of a registered nurse with either the nursing support workforce or a member of another health profession. “(Royal College of Nursing, UK)

The Royal College of Nursing (UK) position on registered nurse substitution and also valuing the role of the registered nurse.

Outcomes

Balancing the economic savings by reducing the skill mix of the nursing workforce by supplementing with enrolled nurses, nursing associate, or unregulated health care assistants may not be fiscally prudent. The impact on patient outcomes such as medication errors, pressure injuries, prolonged length of stay may be more of an economic burden.

Challenges

Who preceptors, role models and supervises newly recruited nurses and graduate nurses if the skill mix is diluted?

Who takes responsibility for the potential increase in both patient and healthcare worker quality outcomes? Would this be communicated from the government, health system levels or the pressure directed down the hierachy to the clinical team and individual responsibility?

At what cost to the healthy work environment and culture would this place on the nursing team?

Time to value nursing – train and retain with measures of the economic impact of the value of a skilled nursing workforce.

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References

Hall LM. (1997). Staff mix models: complementary or substitution roles for nurses. Nurs Adm Q. 21(2):31-9. DOI: 10.1097/00006216-199702120-00007

Jacob, E. R., McKenna, L., & D’Amore, A. (2015). The changing skill mix in nursing: considerations for and against different levels of nurse. Journal of Nursing Management, 23(4), 421-426.

The Royal College of Nursing (UK). (2023). The RCN’s position on registered nurse substitution.

The Royal College of Nursing (UK) (2021). Position statement on preserving safety and harm -valuing the role of the registered nurse.