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Don't dilute nursing skill mix to save money, report warns

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Cash-strapped hospitals should aim to cut overall nursing staff but increase the proportion of qualified or senior nurses, rather than employing cheaper unqualified staff, a report has suggested.

The recommendation goes against the trend seen in the NHS over recent years of trusts attempting to save money by increasing ward ratios of healthcare assistants to registered nurses and cutting specialist nursing posts.

The report Can NHS hospitals do more with less? was published last week by health think tank the Nuffield Trust. It includes a review of research on hospital efficiency, which suggests good nurse management and a “rich skill-mix” can preserve care quality when staff numbers fall.

For example, the review cited US research from the past decade which found surgical death rates worsened sharply with rising workloads where the working environment was poor and only 20% of nurses had degrees. Death rates hardly varied in hospitals with good working environments and 60% of degree-educated nurses.

The report concluded: “Rather than opting for vacancy freezes and lowering skill-mix, there is a need for strategic thinking about nurse staffing in a way that assures a higher ratio of qualified or senior staff, albeit with smaller numbers overall.

“Increasing skill mix appears to be a powerful way of mitigating overall reductions in staff numbers and of assuring improved productivity of nursing care and enhanced patient outcomes.”

The authors concluded that “if reductions in nurse numbers are required, it might be possible to reduce the risk of nurse burnout and rising turnover”, and to maintain or improve care quality by “making nurse management reforms and enriching skill-mix”.

The report also defined a good working environment as one which included a participatory and supportive management style, “adequate” nurse staffing, a decentralised organisational structure, and flexible working schedules.

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