Non-Regulated Health Personnel in Critical Care Areas
Definition
Non-regulated health personnel are becoming known within the Canadian health care system by name, including, but not limited to patient care assistants, assistive personnel, multiskilled workers and nurse auxiliary. These health care workers may provide non-direct and/or direct patient care under the supervision of Registered Nurses, who must then assume some level of accountability and responsibility for them. Their roles and job descriptions are defined by each individual organization and/or unit on which they work. Their educational preparation may vary, usually constituting on-site training versus specialized educational preparation. The public is not protected through registration, provincial legislation, a scope of practice, or the existence of standards of care since there is no regulatory body for these workers.
Background
The public is protected by regulatory bodies for healthcare professionals. Registered Nurses, as members of regulatory bodies, are held responsible and accountable for the care they provide. Registered Nurses are graduates of either college or university programs of study, where they receive a diploma or degree in their field. Their practice reflects a high degree of clinical decision-making ability, and demands ongoing professional educational development throughout the nurse's career. The process involved in the delivery of nursing care represents a complex integration of knowledge, judgement, organization and evaluation. The abilities and scope of practice of the Registered Nurse have been consistently shown to positively affect patient morbidity, mortality and patient satisfaction while maintaining cost-effective health care delivery.
Health care is in crisis. Financial pressures rather than optimal patient outcomes are driving many patient care decisions in health care institutions. Since salaries make up the majority of expenditures for any health care organization, they are, therefore, a primary target when budget cuts are necessary. On the surface, it seems to make sense to lower costs by having the same or similar work performed by a lower paid worker, and hence the introduction of non-regulated health personnel into the clinical setting. However, what is not captured in the decision to introduce these workers into the clinical setting is the invaluable critical-thinking ability that must accompany the care provided to patients. The Registered Nurse ensures safe, quality, cost-effective patient care through comprehensive assessment, analysis, decision-making, intervention and continual evaluation of patient outcomes.
Research
Early anecdotal reports regarding the implementation of non-regulated health personnel seemed promising with regard to patient care and cost effectiveness. However, current research literature consistently demonstrates that care provided by Registered Nurses can reduce morbidity and mortality rates, decrease lengths of stay, and lower readmission rates (Al-Haider & Wan, 1991; Devine & Cook, 1993; Donovan & Lewis, 1987; Hogan & Roher, 1989; Mumford, Schlesinger & Glass, 1982; Prescott, 1993; Shortell & Hughes, 1988). Registered Nurses contribute to the effective management of hospital expenditures and the quality of care by providing services which optimize patient outcomes, satisfaction and ability to function upon discharge (Prescott, 1993). Helt and Jelinek (1988) showed that hospitals incurred an approximated 5% productivity savings while increasing their ratios of Registered Nurses in the care of their clients. This study also indicated that lengths of hospital stay decreased and quality of care scores improved. These impressive results were achieved despite rising patient acuity. When there is a high percentage of Registered Nurses providing care, research data clearly demonstrate that cost savings, improved productivity and reduce lengths of stay consistently outweigh any potential cost savings from the introduction of less skilled caregivers.CACCN's Position
We believe that the quality of patient care for critically ill individuals will be compromised with non-regulated health personnel. The nursing process (assessment, planning, implementation and evaluation) is the domain of the professional Registered Nurse. In the best interest of the public, this nursing expertise should remain with this regulated professional for all facets of patient care.
CACCN members, employed in institutions initiating non-regulated health personnel roles in critical care areas, should be actively involved in the decision-making process that defines these roles. Activities should be focused on non-direct patient care with a clearly outlined job description. These measures will ensure that quality patient care and positive patient outcomes remain the primary goals of all health care providers and organizations.
We believe that the balance between quality care and cost effectiveness can best be managed by Registered Nurses. Non-regulated health personnel have the potential to make positive contributions to the health care environment in certain clinical settings. However, the CACCN does not endorse the use of non-regulated health personnel in direct patient care roles in critical care areas.
References
Al-Haider, A. and Wan, T. (1991). Modelling organizational determinants of hospital mortality. Health Services Research, 26(3), 303-323.
Devine, E. and Cook, T. (1993). A meta-analysis of effects of psychoeducational interventions on length of postsurgical hospital stay. Nursing Research, 32, 267-274.
Donovan, M. and Lewis, G. (1987). Increasing productivity and decreasing costs: The value of RNs. Journal of Nursing Administration, 17(9), 16-18.
Helt, E. and Jelinek, R. (1988). In the wake of cost cutting, nursing productivity and quality improve. Nursing Management, 19(6), 36-48.
Hogan, A. and Roher, J. (1989). The effects of nursing and physician services: Some preliminary results. Social Science Medicine, 29, 527-536.
Mumford, E., Schlesinger, H., and Glass, G. (1982). The effects of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature. American Journal of Public Health, 72, 141-151.
Prescott, P.A. (1993). Nursing: An important component of hospital survival under a reformed health care system. Nursing Economics, 11, 192-199.
Shortell, S. and Hughes, E. (1988). The effects of regulation, competition and ownership on mortality rates among hospital inpatients. The New England Journal of Medicine, 318(17), 1100-1107.