While swapping professional nurses for nursing assistants might seem less expensive for hospitals in the short term, new research suggests it's associated with lower quality of care, increased patient risk and thus higher costs in the long run.
The study, published Tuesday in BMJ Quality and Safety, examined data from hospitals, patients and nurses in Europe. The richer the skill mix of nursing staff, the lower the mortality rates and odds of poor patient ratings or quality reports, it found, although it did not establish a causal relationship or identify specific mechanisms by which outcomes worsened.
“Trying to substitute lower level people in an increasingly complex area is bound to have adverse clinical outcomes,” said lead author Dr. Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia. “Our study shows that it does.”
The study drew on survey data from more than 13,000 nurses across 243 adult acute-care hospitals and more than 18,800 patients in 182 of those hospitals, and discharge data for more than 275,000 surgical patients in 188 of them. The hospitals were located in Belgium, England, Finland, Ireland, Spain and Switzerland.
"Nurses in hospitals with richer skill mixes have lower odds on reporting poorer quality care, lower patient safety, high burnout and job dissatisfaction," the researchers found. Nurses were also more likely to recommend their hospitals and less likely to report problems involving patients including frequent pressure ulcers and falls with injuries. The researchers also found that substituting a nurse assistant for a professional nurse for 25 patients was associated with a 21% rise in the risk of dying.
However, they warned, “We cannot be sure of causal links between skill mix and outcomes.”
The study is salient at a time when hospitals are looking for ways to cut costs, including by changing the skill mix of nursing staff by hiring assistants with less training whom professional nurses would then supervise.
Those efforts have met with attempts at the state and federal level to mandate minimum levels of nurse staffing and skill mix levels. The Registered Nurse Safe Staffing Act has been repeatedly introduced in Congress, although it was never passed. More than a dozen states have enacted legislation or regulations governing the appropriate blend of nursing staff.
Changing nursing skill mixes is not the same as expanding scope of practice, which has also inspired proposals for changes in regulations. In May, for instance, the Veteran Affairs Department proposed authorizing advanced practice registered nurses to give care at the top of their licenses by providing services without clinical oversight from a physician.
The lowest-level credential in nursing is that of a certified nursing assistant—technically not a nurse—which typically requires a high school diploma and the completion of a state-approved program. CNAs provide basic care, such as bathing and transporting patients. In 2015, the median annual salary of a nursing assistant in the U.S. was $25,710.
Providers in the next tier, licensed practical nurses and licensed vocational nurses, must also complete a program, typically a year long. Their duties include registering patient vital signs and administering medications, earning a median salary of $43,170 per year in 2015 in the U.S.
Registered nurses must have an associate or bachelor's degree, and they can assess patients, educate them and provide recommendations for care. In the U.S., their average salary was $67,490 in 2015.
“This is such an enticing idea, that we can solve our problems if we add lower-cost workers,” Aiken said. But, she added, it is “nurses that are driving not only the quality outcomes that hospitals are seeking, but these quality outcomes are associated with bottom-line performance.” She described nurses as “the surveillance capacity for hospitals,” the first to detect when something is not right with a patient and intervene before catastrophe ensues.
Joanne Spetz, a professor at the Institute for Health Policy Studies at the University of California at San Francisco, who was not involved in the research and had not read the study, pointed out that a variety of factors affect quality—financial problems at a hospital, for instance, or poor management—in addition to the skill mix of nurses.
“Maybe the registered nurses haven't been trained well in supervising,” Spetz suggested, as one possibility. She suggested a deeper dive into data to see if any hospitals performed exceptionally well with a low skill mix—or exceptionally badly. That data could be more actionable, especially for hospitals whose budgets may leave them with little choice but to hire nurses with less training.