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What is the ideal nursing skill mix?

  • Comments (27)

What is the ideal nursing skill mix?

Discussion around staffing frequently focuses on numbers of staff.

However the final results report from the RN4CAST study into nursing workforce has shown huge variations in skill mix.

The research found that the average proportion of registered nursing staff - compared to unregistered healthcare assistants - on day shifts was 56%.

Dame Christine Beasley, the previous chief nursing officer for England, has previously said the ratio of nurses to assistants should not fall below 60:40.

The research found the proportion of registered nurses to assistants varied from 43% to 68% between trusts.

  • Comments (27)

Readers' comments (27)

  • Anonymous

    In this country nurse nurse staffing and skill mix depend to a large extent on historical staffing levels.

    There exist many tools(many validated) which can assist in determining nurse staffing levels. The outcomes from many of these tools are described as being aspirational and therefore nothing changes.

    Concentrating effort on "skill/mix" runs the risk of missing the point. No Registered nurse should be required to care for more than 4-6 patients. The higher patients average dependency s the greater demand which is placed on Registered Nurses (again tools exist to measure dependency).

    Management generally dislikes these tools and will argue against using them/or the validity of the tools results especially if they point toward more staff being required.

    The past few years has seen Management deliberately and cynically reduce Registered Nurse Staffing levels in the face of increasing patient dependency. This has been compounded by cynical dilution of skill mix.

    "Whistle Blowing" about staffing levels is not a realistic expectation as staff will be bullied and harassed out of their jobs (Remember Graham Pink?)



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  • I don't think we can come up with a country wide skill mix that will apply in every location, obviously the needs on a HDU unit will differ from A&E, as they will from MAU to the general ward area. However most hospitals will have all of these areas and it should be easy to publish national guidelines for each location.

    With regards to the qualified skill mix to the HCA, this should not be looked on with suspicion. A high level of HCA's, providing direct patient care is surely a good thing, i appreciate they can't replace a qualified nurse, but they do undertake a lot of the personal care that our patients want and demand. (this is not to say nursing does not want to do it, just has competing demands on our time)

    I do however feel that the only way to become serious about this is to commission this as you would do any other service. Only then, when it becomes a trust board objective will you see any change.

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  • Anonymous

    On a busy general med ward I feel safe looking after 6 patients - I still need help from the HCA but 6 would allow me the time to do my job properly. Unfortunately at the moment I have 13 patients which is way too many.

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  • Anonymous

    On a general medical ward and depending on their degree of dependence my maximum is six without assistance and far less if I have a highly dependent patient.
    It very much depends on the ward. For reasons of safety and quality of care i do not accept more than six on the early shift and neither do my colleagues. On the afternoon and evening shifts we can spend a few hours on our own when we have 20 patients and occasionally during a winter crisis 25 (in the corridors and sandwiched between the permanent beds and we have even been known to have oxygen cylinders in the corridors, and even in the old days before smoking was banned!). At night we work a nine hour shift on our own (with an on call doctor) which can be tough.

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  • Anonymous

    it depends on the level of need the patient has and the ned of the ward.... A&E ITU HDU may need a higher skill mix then general wards

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  • Anonymous

    James Bird

    Remember, you are responsible for any task delegated to a health care assistant. If you are happy to have hca's working for/with you that you cannot supervise adequately it is your registration which is at risk.

    No Nurse should be asked to care for more patients than is safe and substituting hca's for RN's will only lead to reduced standards of care and increased levels of morbidity/mortality amongst your patients.

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  • Anonymous



    Anonymous | 21-Aug-2012 10:08 am, 13? Try 16! Highly acute patients too!Staffing levels are a f*****g joke!

    I'd say for every six patients, AT LEAST 1 band 5 staff nurse and 2 HCAs. Then band 6 nurses and coordinators as back up.

    So on a normal average elderly ward of approx 32 patients, that would be 4 qualified staff nurses, plus 8 HCAs, plus at least 2 band 6 nurses as back up, plus coordinators and admin staff.

    That would obviously differ for departments such as HDU, A&E, etc. (and for differ, read increased staffing).

    That is what the literature recommends, is it not?

    Ah, pipe dreams.

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  • Anon 24:08:12 6:19AM
    I do believe you are correct in your statement that an RN would be responsible for all actions of HCAs under their care, and this was going to be the case here in Victoria Australia. It was not passed and not accepted by RNs here.
    RNs here would not and will not work with those conditions put upon RNs.
    SAFE Patient Ratios vary in some areas but we work mainly with 1:4 patients. No HCAs at the minute in the Public Health Sector.
    I am sure at some stage they will be introduced, but RNs here will be very mindful of how they will be monitored to protect their own practices and registration.

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  • And so as to not cause upset, I do believe there is an important role for HCAs here as valuable team members, however there should be strict guidelines as to what their job role involves, and who is responsible for their practice.

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  • Skill mix, skill mix
    Now we need a quick fix
    If we are to save our jobs at all

    On the subject of nurses
    Let’s be serious
    Managers fire them as quick as their employers hire them
    As nobody can agree what this mix should be.

    Nobody left to wash as too many new nurses think themselves too posh
    They will not carry out the most menial task even when their patients ask
    Others really do give care but only on nights when they dare
    When nobody else is about
    Oh, what a tragic affair

    Skill mix, skill mix
    Now we need a quick fix
    If we are to save our jobs at all

    Now is the time to get this right if we with our managers
    Do not want a great fight
    They have plenty of ammunition
    While our only weapon is our ambition

    Skill mix, skill mix
    Now we need a quick fix
    If we are to save our jobs at all
    Now is the time we have to act
    To establish the fact
    That we need many more nurses
    If all our patients are not to be carried off in black hearses

    Skill mix, skill mix
    Now we need a quick fix
    If we are to save our jobs
    And our patients at all
    And very fast before we all fall.

    Skill mix, skill mix
    Please give us a quick fix.
    Please give it very soon as
    Delirium tremens will set in by noon.
    It is not too soon to save us all from
    Such a tragic downward spiralling fall.



    Please add your own Raps, ditties, poems, etc. on any theme to any page or under the article below. Some are to be published in NT Magazine.


    The big question: do people still believe nurses with degrees are too posh to wash?
    16 August, 2012

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  • Anonymous

    HCAs are responsible for their own actions - it is a myth that qualified nurses are. An HCA should only undertake work that they are trained to do, if they make a mistake then they are accountable, not the qualified nurse.

    If a staff nurse delegates a task to an HCA who is not competent to undertake that task but carries on regardless then both are accountable.

    It is the responsibility of the employer to ensure that HCAs receive training before they work on the wards.

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  • Anonymous

    I work in a care home with 45 residents, half of which are nursing. On shift there is one nurse and between three and nine carers, depending on the time of day. I am told there only needs to be one nurse to look afte the twenty two nursing residents.

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  • Anonymous

    There is no way you can provide adequate care to 27 patients some of which have had major orthopaedic operations that day some are elderly and confussed and some should be nursed in HDU on a 10 and a half hour night shift with two trained staff nurses and one HCA and a Dr covering ED and three other wards who has no experience in orthopaedics!!! Totally unsafe!

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  • Nurses! Fahsends of em!

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  • Anonymous

    ...and not having the right skill mix wastes resources and reduces job satifaction, motivation, feeling valued etc.

    I just like to present an alter view even though I agree with most of the above posts. I have also worked with three HCAs in primary care, two of which I helped train who had more initiative and motivation than 'some' qualified nurses I have worked with.

    Now I don't have a HCA I am frustrated in my role because 40% of my work does not actually need a qualified nurse to do it but GPs and non-clinical managers who employ me don't seem to know, let alone car about it even though they pay me Level 6.

    I offered to drop my hours so they could afford a HCA (though both GPs own second homes) but I was declined.

    Like we have a skill level to help decide a grade, I think each department should have a skill mix recommendation otherwise it is a loose cannon waiting to go off, either wasting resources or nurses stretched till they drop of get sued.

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  • Anonymous

    redpaddys12 | 28-Aug-2012 4:17 am

    Awful spelling!

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  • Anonymous

    Anonymous | 28-Aug-2012 3:03 pm

    perhaps it is Irish?

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  • Anonymous

    I read with interest the skill mixes, I work on an acute admissions ward in a secure unit looking after 10 very unwell and potentially dangerous patients. It appears that in general hospitals the mix is different, in this secure mental health unit I work alone as the only staff nurse with 6 HCA's! I also cover 2 wards should another nurse on their ward have a break. OK it's less of a case of life or death on psychiatric wards... but still, you think you have it bad!

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  • Not Irish, Michael Caine! Not a lot of people know that!

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  • Anonymous

    must be Cockney then. Michael Caine came from and was born in south London.

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