Replacing registered nurses isn’t the answer to rising health costs

Replacing registered and enrolled nurses with lower-skilled workers leads to poorer patient outcomes. DIBP images, CC BY-SA

A shortage of qualified nursing staff and rising health costs have led to an increase in the employment of unregulated nursing workers.

In 2012, the average weekly salary for full-time nursing professionals in non-managerial positions was $1,633.50; the salary of an assistant in nursing ranges between 55% and 77% of this. Therefore substituting registered nurses saves money.

There are many titles used to refer to these staff but in Australia they are usually referred to as assistants in nursing and, less frequently, patient care assistants or personal care attendants. There are around 64,000 assistants in nursing, comprising approximately 25% of Australia’s nursing workforce.

Assistants in nursing may be cheaper, but replacing large numbers of registered nurses with low-skilled staff is not the answer to the nation’s health budget crisis. On the contrary, it poses a risk to patient safety and is likely to result in poorer outcomes.

Nursing models

Australia has two regulated levels of nurse: registered nurses (RNs), who are trained in a three-year undergraduate university course; and enrolled nurses (ENs), who undergo vocational education and training at TAFEs or other institutions. The Nursing and Midwifery Board regulates both groups.

In contrast, assistants in nursing are not registered or regulated, and there is no mandated educational requirement. RNs and ENs supervise their work and employers are responsible for defining their essential functions and duties. Employers are also responsible for ensuring assistants in nursing have the skills and knowledge needed to undertake these duties.

There are two methods of introducing assistants in nursing to a ward, both of which change the mix of staff and the approach to care. The first, and most common, is substitution where assistants in nursing replace RNs and ENs.

The second approach is a complementary model whereby assistants in nursing are added to ward staffing. The total number of hours of patient care provided increases and the number of hours provided by RNs and ENs is maintained.

Role substitution

The role of assistants in nursing has changed dramatically over the past 30 years. In the 1980s, they assisted RNs and ENs with tasks such as bed making and helped make patients more comfortable. This progressed to activities such as bathing, feeding and helping patients move around and go to the toilet.

Increasingly, assistants in nursing are involved in taking blood pressure and blood glucose levels, dressing wounds and, in some extreme cases, performing venepuncture (puncturing a vein to take blood).

Concern is growing that assistants in nursing will be expected to take on more patient care as workforce shortages persist. More importantly, there is concern that assistants in nursing often don’t have the knowledge, training and support to undertake an increasing range of tasks safely.

International research, including from Australia, has found that decreasing the hours of care provided by RNs and ENs through substitution with assistants results in poorer patient outcomes and can increase the risk of complications and even death.

In particular, reduced RN staffing has been shown to increase the risk of hospital-acquired pneumonia, cardiac arrest and deaths due to surgical complications because of inadequate monitoring.

Research shows RNs are best qualified to accurately detect problems and intervene in a timely and effective fashion. Indeed, a recently published study suggests patient outcomes are even better where there is a higher proportion of degree-qualified nurses providing care.

Replacing RNs and ENs with assistants in nursing also adds to the workload of regulated staff as more supervision is required. This results in less job satisfaction and reduced staff retention.

There is also some evidence that this model of staffing leads to nursing tasks being left undone, such as skin care to reduce pressure sores, and oral hygiene.

Complementary staffing

In contrast to the substitution model, introducing assistants in nursing using a complementary staffing model has been shown to have positive effects.

When assistants in nursing regularly visit patients on rounds (usually hourly), patients’ needs can be met immediately. Knowing someone will be there shortly, patients are less likely to ring their call bells or try to get out of bed by themselves. And regulated workers are less likely to be interrupted during other activities such as administering medications, thereby increasing efficiency and decreasing risks to patient safety.

As the population ages and patient acuity increases, there is little doubt that the demand for hospital care in Australia will continue to increase while workforce shortages persist. But preparing more registered and enrolled nurses is costly and unnecessary.

Increased demands for care, resulting in increased workloads for nursing staff, can be ameliorated with the addition of assistants in nursing to current hospital staffing (a complementary model). This growth in the employment of assistants in nursing will require change nationally.

But in order to protect the public, assistants in nursing should be accountable for the care they deliver and therefore must be registered with a regulatory body. This would ensure a standardised approach to vocational education and training.

Further reading:

Leave prescribing to doctors and nurse practitioners

Hospital workforce reform: better jobs and more care

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