Do you agree with either of the following statements?
Nurses can take on many of the roles traditionally undertaken by doctors, delivering equal or improved quality of care at a lower cost.|
Much of the work currently undertaken by registered nurses can be undertaken by less qualified unregistered professionals.
Canvassing audience responses to the above propositions was how international health workforce researcher Professor Peter Griffiths kicked off his keynote presentation at this year’s Australian Nursing and Midwifery Federation (SA Branch) Annual Professional Conference.
Attendees overwhelming agreed with the first statement but less so with the second—a result that didn’t surprise Professor Griffiths.
“Nurses rarely have much problem endorsing that they can take on the role of doctors but are less inclined to agree that they can be replaced by someone less qualified,” he says.
A clinical nurse by background, Professor Griffiths has worked closely with UK and international health policy makers in a number of capacities and is currently Chair of Health Services Research at the University of Southampton. His long history of health services research has largely focused on the nursing workforce and skill mix.
“When we talk about the staffing and skills mix of the nursing workforce, we’re talking about the quality of care and ultimately matters of life and death for the users of a healthcare system.”
“There’s only one objective around professional advancement and that is whether it provides better care to your patients.”
“The quality of health care being delivered to people should be the pre-occupation of researchers and workforce planners.”
He says that over optimistic reactions to some positive early research on an experimental nurse-led inpatient ward led to newspaper headlines such as ‘Doing Away with Doctors.’ Although the case for nurses to have a greater role in patient care was strengthened by the findings of a 1995 report, later findings, including his own, gave much more reason for caution.
“There’s a real danger to patient outcomes if we’re led by unconfirmed research, even if it appears to be telling us what we want to hear.”
Although there is evidence that nurses can safely substitute for doctors in some health settings, in primary care for example, evidence on cost effectiveness is often lacking.
“While there is hugely influential research associating nurse staffing levels with patient safety in acute environments, the skill mix of staff has been subsequently proven to be a key factor.”
He said nurses (and midwives) can substitute for doctors under some circumstances but this does not necessarily equal cheaper care, although in primary care it seems that nurse-led care costs no more and might save money while still improving quality.
In the same way, there is also no evidence to suggest replacing Registered Nurses with Assistants in Nursing drives cost-efficiencies. In fact, there is some evidence emerging that suggests it might cost more because outcomes are not as good.
And economic arguments are influential when you consider the growth of the healthcare workforce.
“The delivery of healthcare is labour intensive and is not reducing despite changes in technology.”
In England alone, its public health service (the NHS) employs 1.2 million people, around 40% more employees than 20-plus years ago.
Looking at studies on the links between nurse staffing levels and outcomes of hospital care, including death rates, Professor Griffiths said, unsurprisingly, increases to total staffing levels cost more money.
“If you calculate the ‘cost per life saved’ from economic studies of increases in nurse staffing, you get a range of figures depending on what changes are proposed and where the study was done. Apart from one well known Australian study, these results don’t necessarily look like good value, but we have to remember that costs in the US are very different and there is much more ‘value’ from improved nursing care than reduced death rates.
Ultimately, Professor Griffiths says the best value for money, based on all evidence, is achieved by improving the skill mix while keeping the same number of nurses. Although higher skilled staff cost more, the increased costs are more than offset by savings from improved care, for example, reduced hospital stays.
He also says it’s vital for hospital managers to be able to experiment and innovate, provided they have an evidence base to guide any proposed changes.
“We wouldn’t introduce a new drug without evaluating its effectiveness, but we seem all too willing to do this with our practitioners.”
One tragic example he cites was the decision by a UK hospital to reconfigure its wards onto three floors which has been linked to up to 1200 unnecessary deaths.
“Finance was considered to be a crucial factor to move those wards—and there seemed to be no evidence base to do so.”
Also linked to the failings at the Stafford Hospital was management’s decision to replace a number of Registered Nurses with more junior Assistants in Nursing.
“We don’t yet know what the best or the right skill mix is, but we do know the value of highly skilled practitioners.”
And when it comes to their role in the future, both professions—nursing and medical—must be able to adapt to future demands.
“Whether we have doctors and nurses as we currently know them in the years ahead, we do need to be assured that all professions are well trained to deliver high-quality care.”
“If we focus on training them for today’s healthcare needs and enable the workforce to continue to learn and adapt we will produce a workforce fit for the future.
“And nurses have a vital role in the future of healthcare no matter what that future looks like. I certainly hope that future is one where professional nurses are still delivering ‘hands on’ nursing care because that’s where we know they can deliver the most benefit for patients and the best value for the health system.”