Optimizing the nursing skill mix: A win for nurses, patients, and hospitals

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Traditionally, hospitals have focused on productivity (hours per unit of service, such as patient day) to determine staffing levels. However, this approach creates unintended incentives to reduce the number of staff members on the floor, which then limits the time spent on patient care.

Optimizing the nursing skill mix enables hospitals to lower their costs (see Exhibit), but it also does much more: It allows registered nurses (RNs) to practice at the top of their license (for example, by spending more time on patient education), which generally leads to higher job satisfaction. And higher satisfaction often lowers staff turnover, resulting in additional cost savings. Patients benefit as well, because increased staff time at the bedside correlates with improved outcomes.


A hospital’s ability to provide high-quality care depends largely on its frontline personnel – they must be engaged and appropriately skilled to ensure that they can function seamlessly within a team-based delivery model. However, many hospitals have difficulty achieving the right kind of hospital staffing. Among the challenges they face:

  • The U.S. (among other developed and developing markets)  is experiencing shortages of qualified clinical care providers
  • Today’s patient population requires increasingly complex care
  • Many hospitals, faced with growing pressures to protect financial margins, are mandating nursing staff ratios or hourly productivity targets that ignore skill mix and total cost, leaving clinicians, especially nurses, feeling overburdened

The first two factors, as well as today’s reimbursement pressures, are beyond a hospital’s ability to control. Hospitals must therefore find ways to provide high-quality care despite these challenges. After working with multiple healthcare systems in the US, UK, and elsewhere, we have found that one of the best ways hospitals can achieve this goal is by optimizing the nursing skill mix – they maximize patient care time by using lower-paid staff to perform less complex tasks, freeing up the more highly qualified staff to focus on tasks only they are qualified to undertake. For example, helping patients walk does not require a fully trained RN. That task can be performed by unlicensed staff members as long as they are given the right training.

This skill mix shift results in the same number of hours with the patient, but at a lower total cost without sacrificing top quality care. By optimizing the nursing skill mix around both patient needs and total cost, hospitals can deliver safe, effective, high-quality care in a fiscally responsible manner.

Getting from here to there

The essential first step in optimizing the nursing skill mix is to open a dialog with the nursing teams and other clinicians at the frontline. They usually have a clear understanding of the patient-care tasks needed most often and of which staff members are qualified to perform them, which can enable hospital leaders to begin better matching patient needs with staffing resources. The frontline clinicians can also help establish the evidence base needed to ensure that quality of care is not compromised and that the nursing teams’ goals can be met. To then achieve appropriate skill mix in a unit, standards must be set around what mix of labor to staff based on varying levels of patient demand. Impact and productivity then must be measured in total cost and quality rather than solely an hourly figure.

Many hospitals have found it helpful to conduct an initial pilot in one unit when they begin a program to optimize the nursing skill mix. The pilot usually provides rapid “proof of concept” that can be used to overcome any skepticism the staff may have, as well useful lessons about how to apply the approach in other units.

Several other steps can also help ensure the success of any program to optimize the nursing skill mix:

  • At the start of the program, leaders and frontline staff should agree on key performance metrics (e.g., salary, wages and benefits per acuity-adjusted patient-day; employee and patient satisfaction scores; quality of care scores).
  • All staff members should be held accountable for their part of the program, but they should be supported through formal mechanisms designed to promote the achievement of target outcomes.
  • Leaders should use a clear and consistent communication strategy to emphasize the holistic benefits of achieving an optimal skill mix, especially when the program is rolled out throughout the hospital.
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