Improving Utilisation of Assitants in Nursing: Staffing, Skill Mix And Outcomes

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Michael Roche, Senior Lecturer, Faculty of Nursing, Midwifery and Health, UTS delivered this presentation as part of the 2012 Assistants in Nursing Conference – A conference for organisations and managers looking to better understand and utilise the assistant in nursing role. For more information about the event, please visit the conference website: http://goo.gl/fvWjc

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Improving Utilisation of Assitants in Nursing: Staffing, Skill Mix And Outcomes

  1. 1. AINs, Staffing, Skill Mix & OutcomesA Research PerspectiveMichael RocheCentre for Health Services ManagementUniversity of Technology, Sydney
  2. 2. • 81900 Nursing andpersonal careassistants employedin the health sectorin 2010• 23.5% of total RNs,ENs and AINs» (AIHW, 2012)Changesince 2005Changesince 2001AIN +14% +97%RN+EN +16% +30%All +15% +46%BackgroundCENTRE FOR HEALTH SERVICES MANAGEMENT 2
  3. 3. • Limited research onthe impact of AINs• Settings– Aged care– Acute medical orsurgical• Nursing activities– Roles & tasks• Links to patientoutcomes– Skill mix– Practice environment– Workload– Turnover & retentionPublished ResearchCENTRE FOR HEALTH SERVICES MANAGEMENT 3
  4. 4. Skill Mix: Replacement & Augmentation• Evidence on the effect of replacing RegisteredNurses with unqualified nursing assistants is limited» (Butler, et al., 2011)• Most studies have identified a replacement model -where RNs have been substituted with otherworkers (ENs or AINs)– Few studies have examined:• The impact of replacement of RNs with AINs• The impact of augmentation of current staffing with AINs (i.e.an addition model)CENTRE FOR HEALTH SERVICES MANAGEMENT 4
  5. 5. Skill Mix: McGillis-Hall (2001; 2003)• Compared wards with different staffing mixes– Regulated (RN Only; RN/EN) and Unregulated (RN/AIN & RN/EN/AIN)• Wards with higher % regulated staff:– Better patient outcomes (functional independence, pain,social functioning, and satisfaction)– Lower rates of medication errors and wound infections• Wards with lower % regulated staff:– RNs reported greater job satisfaction– Lower perceived quality of care– Used more nursing hours per patientCENTRE FOR HEALTH SERVICES MANAGEMENT 5
  6. 6. Skill Mix• Richer skill mix (% of RN staffing hours) linked to:– Lower rates of nurse-sensitive outcomes (UTI, pressure ulcers,sepsis, pneumonia, GI bleed…)» (Duffield, et al., 2011)– Lower rates of aggression (in turn linked to fewer falls andmedication errors)» (Roche et al., 2010)• Leaner skill mix linked to increased LOS and higher costs» (Cho, et al., 2003)• An increase of 10% in the percentage of RN hours linkedto:– Reduction of between 11% (pneumonia) and 37% (GI bleed);approx. 11 fewer cases per ward per year» (Roche et al., 2012)CENTRE FOR HEALTH SERVICES MANAGEMENT 6
  7. 7. NEW DESCRIPTIVE ANALYSES2004-2010CENTRE FOR HEALTH SERVICES MANAGEMENT 7
  8. 8. • Nurse survey datasets– Australian (cross-state)– Medical & Surgicalwards– N=~8000– Various data elements,not all present in alldatasets• Subsets or merged datafor analyses• Skill mix• Practice settings• Job satisfaction• Intention to leave• Practice environment• Workload• Tasks & RolesDatasets & FactorsCENTRE FOR HEALTH SERVICES MANAGEMENT 8
  9. 9. Analysis: Assistants in Nursing• Mean Age 30– RN (38) & EN (40)• 80% casually employed• 27% on permanent contracts• Working for an average 18 hours/week• Mean 3.8 years experience– Range <1 to ~15• Qualifications– 46% Certificate, 23% BN (completing), 31% No QualificationCENTRE FOR HEALTH SERVICES MANAGEMENT 9
  10. 10. Analysis: Settings & Skill Mix(N=7875) RN EN AINAdult medical 70.8% 27.7% 1.5%Adult medical-surgical 65.7% 33.1% 1.1%Adult surgical 74.5% 23.9% 1.6%Other 88.4% 11.6% 0.1%CENTRE FOR HEALTH SERVICES MANAGEMENT 10Ward AIN skill mix:Mean 2.4% SD=4.39 Range 0%-22% (N=142)
  11. 11. PRACTICE ENVIRONMENT,WORKLOAD & TURNOVERJob satisfactionIntent to leave current positionActively looking for another jobCENTRE FOR HEALTH SERVICES MANAGEMENT 11
  12. 12. Practice Environment & Workload• Supervisory/leadership skills have been identified asneeding improvement» (Siegel et al., 2008)• Perceived lack of respect & recognition frommanagers» (Bowers, 2003; Lapane & Hughes, 2007)• Perceived greater job demands & job strain thanRNs» (Morgan, et al., 2002)• In nursing homes, AINs at greater risk of assault thanother workers» (Gerberich et al., 2008)CENTRE FOR HEALTH SERVICES MANAGEMENT 12
  13. 13. • Less likely than RNs &ENs to experiencephysical or verbalaggression– ~10% AINs– ~20% RN/EN• Higher scores onpractice environmentscales– (Note: NWI-PES not well-validated withthis group)• Fewer tasks delayedeach shift– ~2.5 AINs– ~4 RN/EN• Fewer tasks leftundone at the end ofshift– ~0.6 AINs– ~1 RN/ENAnalysis: Practice Environment & WorkloadCENTRE FOR HEALTH SERVICES MANAGEMENT 13
  14. 14. Turnover• High turnover rate in long-term care & shortagespredicted to increase in the U.S.» (Meyer, et al., 2012)• In Australia, 20% of AINs are over 55 years old(similar to RNs)» (AIHW, 2012)• Some differences in the relationship betweenempowerment and burnout amongst AINs,compared to RNs» (Hochwalder, 2008)CENTRE FOR HEALTH SERVICES MANAGEMENT 14
  15. 15. Analysis:Job Satisfaction• 82.7% Moderately orvery satisfied withtheir current position• (N=2213)• McCloskey-MuellerSatisfaction Scale• Scored higher onsatisfaction withControl &Responsibility thanRNs, ENs and others• (N=1679)CENTRE FOR HEALTH SERVICES MANAGEMENT 15
  16. 16. Intent to Leave• 48% intend to leavewithin the next year– Significantly (p≤0.05) morelikely than EN (19%) & RN(27%)• 28% actively looking for anew job– EN (13%) & RN (21%)» (N=3899)Actively LookingAnalysis: TurnoverCENTRE FOR HEALTH SERVICES MANAGEMENT 16
  17. 17. Analysis: Absenteeism• On average, AINsmissed work 1.8times during the pastyear• Fewer than ENs(4.6) & RNs (4.1)• AINs missed anaverage of 2.3 shifts• ENs (5.5) & RNs (4.9)• Both comparisonsstatisticallysignificant (p≤0.05)CENTRE FOR HEALTH SERVICES MANAGEMENT 17
  18. 18. TASKS & MODELS OF CARETasks complete in the last shiftModel of care „most shifts‟CENTRE FOR HEALTH SERVICES MANAGEMENT 18
  19. 19. Role Clarity• Mismatches between the model of care (e.g. patientassignment, team nursing) and staff mix, appear to belinked to job satisfaction and stress» (Tran et al., 2010)• Challenges in teamwork and role clarity– Delegation– Work group cohesion» (Cleary, et al., 2012; McGillis-Hall, 2003; Tran et al., 2010)• “RNs and AINs were expected to share the responsibilityfor completing hourly rounding but … were unsure howto divide up the rounding responsibility with each otherfor their shifts”» (Deitrick, et al., 2012)CENTRE FOR HEALTH SERVICES MANAGEMENT 19
  20. 20. Analysis: AIN Views of Models of Care0 1 2 3I have overall 24 hour responsibility for a groupof patients and manage their nursing care fromadmission to dischargeI provide almost all of the care for our assignedpatients throughout the shift but I may not havethe same patients from their admission to…We work as a team or group of nursing staff overthe shift and together work to provide care to agroup of patientsWe look at the tasks that need to be completedon the shift for patients and assign staff varioustasksMeanCENTRE FOR HEALTH SERVICES MANAGEMENT 20
  21. 21. • Showering & bathing• Oral, eye, ear care• Assistance with toileting– Simple FBC & Stool chart• Assistance with patientmeals and fluids– Simple FBC• Observe and report– TPR, BP, BSL, etc.• Patient escort• Pressure area and skincare• Positioning and comfort• Assistance withmobilisation• Specimen collection• Simple wound dressings» (NSW Health, 2010)A short list of tasksCENTRE FOR HEALTH SERVICES MANAGEMENT 21
  22. 22. Analysis: Tasks Last Shift• Which of the following tasks did you performduring your last shift?CENTRE FOR HEALTH SERVICES MANAGEMENT 22
  23. 23. Delivered/Retrieved Meal Trays0.00%5.00%10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%Trainee Enrolled Nurse Assistant in Nursing Enrolled Nurse,including EENRegistered Nurse Education/developmentnurseSenior/specialist nurseCENTRE FOR HEALTH SERVICES MANAGEMENT 23
  24. 24. Housekeeping Duties0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%Trainee Enrolled Nurse Assistant in Nursing Enrolled Nurse,including EENRegistered Nurse Education/developmentnurseSenior/specialist nurseCENTRE FOR HEALTH SERVICES MANAGEMENT 24
  25. 25. Transported Patients0.00%5.00%10.00%15.00%20.00%25.00%30.00%35.00%Trainee Enrolled Nurse Assistant in Nursing Enrolled Nurse,including EENRegistered Nurse Education/developmentnurseSenior/specialist nurseCENTRE FOR HEALTH SERVICES MANAGEMENT 25
  26. 26. Arranged Discharge Referrals/Transport0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%Trainee Enrolled Nurse Assistant in Nursing Enrolled Nurse,including EENRegistered Nurse Education/developmentnurseSenior/specialist nurseCENTRE FOR HEALTH SERVICES MANAGEMENT 26
  27. 27. Duties such as ECGs and starting IVs0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%100.00%Trainee Enrolled Nurse Assistant in Nursing Enrolled Nurse,including EENRegistered Nurse Education/developmentnurseSenior/specialist nurseCENTRE FOR HEALTH SERVICES MANAGEMENT 27
  28. 28. Ordering, coordinating or helping perform other disciplinary services(e.g. physiotherapy, blood tests)0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%Trainee Enrolled Nurse Assistant in Nursing Enrolled Nurse,including EENRegistered Nurse Education/developmentnurseSenior/specialist nurseCENTRE FOR HEALTH SERVICES MANAGEMENT 28
  29. 29. Met RN expectations• Physical observations– (TPR, BP, BSL, etc)• Prescribed closeobservation• Bed making• ADLs• Group activitiesDid not meet RN expectations• Interacting with patients• Writing patient notes• Assessing the mental stateof patients• Management of aggression• Assessment of medicationside-effects» (Cleary et al., 2012)An example from Mental Health:Tasks undertaken by AINs (enrolled in BN courses)CENTRE FOR HEALTH SERVICES MANAGEMENT 29
  30. 30. Role Clarity / Ambiguity / Conflict• “Assistants were perceived to be performingsome „advanced‟ technical activities”– Admission assessments– Care planning» (Spilsbury, et al., 2011)CENTRE FOR HEALTH SERVICES MANAGEMENT 30
  31. 31. Summary• Generally satisfied, with a positive perception ofthe work environment and fewer absences• Also more likely to intend to leave and to beactively looking for a new job– How to build on the satisfaction and retain?• Fewer tasks delayed or left undone– Is this appropriate workload?• Scope of practice– Is it being adapted by experienced AINs and/or by AINsnear completion of BN courses – how to monitor practice?CENTRE FOR HEALTH SERVICES MANAGEMENT 31
  32. 32. What do we know?• Richer skill mix links tobetter patient outcomes• Differences in outcomes forAINs– Job satisfaction– Control & responsibility– Intent to leave• Variation in role/scope– Apparent variation betweenexpected role & actual roleNeed to know more• Specific impact of AINs onoutcomes (patient & nurse)• Actual roles of AINs,particularly in acute settings• Influence of AINs on othernurses‟ roles and the practiceenvironment– Both substitution & addition• Models of care for bestpractice with AINs• … … … … … … … … … … … …SummaryCENTRE FOR HEALTH SERVICES MANAGEMENT 32

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