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Article
The Use of Unregulated Staff: Time for
Regulation?
Christine M. Duffield, PhD, MHP, BScN, RN, FACN, FACHSM,
FAAN
1,2,3
, Di E. Twigg, PhD, MBA, BSc(Hons), RN, RM, FACN,
FACHSM
2,3
, Judith D. Pugh, PhD, MEd, PGradDipCurricEdTech,
RN
4
, Gemma Evans, RN, BSc(Hons)
2
, Sofia Dimitrelis, MPhil,
MPharm, BMedSci
1
, and Michael A. Roche, PhD, RN, MHSc, BScN,
DipAppScN
1
Abstract
Internationally, shortages in the nursing workforce, escalating patient demands, and financial constraints within the health
system have led to the growth of unlicensed nursing support workers. Recently, in relation to the largest publicly funded
health system (National Health Service), it was reported that extensive substitution of registered nurses with unskilled
nursing support workers resulted in inadequate patient care, increased morbidity and mortality rates, and negative nurse
outcomes. We argue that it is timely to consider regulation of nursing support workers with their role and scope of practice
clearly defined. Further, the addition of these workers in a complementary model of care (rather than substitutive model)
should also be explored in future research, in terms of impact on patient and nurse outcomes.
Keywords
nursing support worker, registered nurse, regulation, skill mix, scope of practice, patient outcomes
Introduction and Background
Poor nursing care leading to patients’ death and disabil-
ity has forced several countries to conduct inquiries into
their hospital systems. The most recent and perhaps the
most significant, because of the scale of deliberations,
occurred in 2013 in the National Health Service (NHS)
England, within the largest publicly funded health ser-
vice worldwide. The Mid Staffordshire Hospital Inquiry
investigated avoidable deaths that occurred between
January 2005 and March 2009 and was damning about
the poor quality of nursing care (Francis, 2010). The
findings included, but were not limited to, failures in
administering prescribed medications and inadequate
completion of nursing records, medical rounds, and nur-
sing handovers (Francis, 2013). Although, surprisingly,
the inquiry was unable to ascertain the number of nurses
employed, media reports indicated that there was exten-
sive substitution of registered nurses (RNs) with unli-
censed nursing support workers, which at times
reached levels of 50% of caregivers (Francis, 2013).
This was despite recommendations from earlier inquiries
(2007–2008) in the same Trust that the skill mix of 40:60
skilled (qualified) nurses to unskilled (nursing support
workers) be reversed to 60:40. This echoed an issue iden-
tified in earlier studies, where a reduction in nursing
1
Centre for Health Services Management, Faculty of Health, University of
Technology, Sydney, NSW, Australia
2
Clinical Nursing and Midwifery Research Centre, School of Nursing and
Midwifery, Edith Cowan University, Joondalup, Perth, WA, Australia
3
Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands,
Perth, WA, Australia
4
School of Nursing and Midwifery, Edith Cowan University, Joondalup,
Perth, WA, Australia
Corresponding Author:
Christine M. Duffield, PhD, MHP, BScN, RN, FACN, FACHSM, FAAN,
Centre for Health Services Management, Faculty of Health, University of
Technology, Sydney: Health (CB10.07.208), PO Box 123, Broadway, NSW
2007, Australia.
Email: Christine.Duffield@uts.edu.au
Policy, Politics, & Nursing Practice
2014, Vol. 15(1–2) 42–48
!The Author(s) 2014
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DOI: 10.1177/1527154414529337
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teamwork and the quality of care was associated with a
high proportion of nursing support workers in the work-
force (Spilsbury & Meyer, 2005). Indeed, lean skill mix (a
high percentage of unskilled workers) has been linked to
numerous negative patient outcomes (Kane, Shamliyan,
Mueller, Duval, & Wilt, 2007; Needleman et al., 2011;
Roche, Duffield, Aisbett, Diers, & Stasa, 2012; Twigg,
Duffield, Bremner, Rapley, & Finn, 2012). In view of this
research and other findings, it is timely to consider the
current state of nursing support worker employment, the
role and scope of practice of nursing support workers,
and the impact on patients and nurses, with a view to
regulation of these workers.
Definition
There are many titles used to refer to unregulated nur-
sing workers, which leads to confusing terminology: unli-
censed assistive personnel (United States); health care
assistants (United Kingdom and Australia); personal
care attendants (Australia); auxiliaries or auxiliary
nurses; patient care assistants, birth assistants, and psy-
chiatric aides; and assistants in nursing (Australia).
Other titles found in the literature include medical assist-
ant, patient care technician, care extender, nurse aide,
nurse tech, nursing orderlies, and attendants. The
International Standard Classification of Occupations
(ISCO 2008) categorizes all these unlicensed workers
under the occupation title of “Patient Care Workers in
Health Services” (International Labour Organization,
2012). The generic title “nursing support workers” will
be used throughout this article.
Nursing Support Worker Employment
The employment of nursing support workers has been
increasing over the past few years. Two significant fac-
tors driving this growth are nursing shortages and the
increased costs of care (Gillen & Graffin, 2010; Graham
& Duffield, 2010; Heath, 2002; Sibbald, Shen, &
McBride, 2004). In the United States, nursing assistants
comprise an estimated 24.7% (593,490) of the more than
2.4 million paraprofessionals (Squillace, Remsburg,
Bercovitz, Rosenoff, & Branden, 2007) and close to
72% (1.45 million) of the direct care nursing home work-
force in 2006 (Bureau of Labor Statistics, 2008). These
figures are mirrored in other countries. For example,
nursing support workers represent approximately 24%
of the entire UK NHS workforce with roughly 332,000
support staff (Department of Health, 2013). In England
alone, the figure is approximately 40%, with 669,953
staff registered with the Nursing and Midwifery
Council (Buchan & Seccombe, 2012) and 286,000 assist-
ant staff employed (NHS Information Centre Workforce
and Facilities Team, 2009); in Australia, it is 25% with
257,200 RNs and 64,600 nursing support workers
(Australian Bureau of Statistics [ABS], 2013;
Australian Institute of Health and Welfare, 2008).
Internationally, nursing shortages are well docu-
mented. Despite some slowing of the exit rate following
the global financial crisis (GFC) in 2007–2008, RN
shortages persist in many countries. For example, in
the United States, shortages are predicted to continue
but have been revised down from more than 1 million
nurses by 2020 to 260,000 by 2025 (Littlejohn, Campbell,
Collins-McNeil, & Khayile, 2012). In the United
Kingdom, a shortage of 42,807 (12.2%) is predicted in
2021/2022 (Buchan & Seccombe, 2012); in Australia,
109,000 (27%) by 2025 (Health Workforce Australia,
2012). Shortages in the regulated nursing workforce
lead inevitably to the increased use of nursing support
workers, particularly as the costs of health care continue
to rise (Keeney, Hasson, McKenna, & Gillen, 2005;
Marshall, 2006). In the United States, 17.6% of the
GDP is now directed toward health, the highest of any
developed country (Organisation for Economic Co-
operation and Development [OECD], 2012). Compared
with the United Kingdom, which has the largest publicly
funded health service, this rate is 9.6% and in Australia
(also a publicly funded system) 9.1% of GDP (OECD,
2012). The salary cost of a nursing support worker
ranges from 40% to 80% of an RN salary: roughly
37% in the United States (Bureau of Labor Statistics,
2013), 63% in the United Kingdom (National Health
Service Careers, 2013), and between 55% and 77% in
Australia (ABS, 2013; ACT Health, 2011). It is under-
standable that the employment of nursing support work-
ers has increased over the years.
Role and Scope of Practice
The role of nursing support workers has also changed
over time. In the 1980s, they performed ancillary, non-
nursing work (McKenna, Hasson, & Keeney, 2004), but
more recently their role has extended to undertaking
activities previously provided by licensed workers
(Australian Nursing Federation, 2008; Maben &
Griffiths, 2008), leading to greater concern about their
increasing role in patient care. Activities in which they
may be involved include bathing and dressing, feeding,
helping people to mobilize, toileting, bed making, gener-
ally assisting with patients’ overall comfort, and moni-
toring patients’ conditions (Bureau of Labor Statistics,
2013; National Health Service Careers, 2006). More
importantly, some nursing support workers record clin-
ical observations, including blood pressure, temperature,
and fluid balance; collect specimens; monitor blood glu-
cose; perform venepuncture and remove intravenous
cannulae; conduct simple wound cleansing and dressings;
and perform cardiopulmonary resuscitation (Bureau of
Duffield et al. 43
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Labor Statistics, 2013; NSW Department of Health,
2010). There is a growing debate around whether nursing
support workers have the requisite knowledge, training,
and support to undertake an increasing range of tasks
safely. Training, which usually permits them to work
according to protocols (Rimmer & Hand, 2010), varies
from no training required through to a program that
lasts anywhere between 6 days and 6 weeks (Keeney
et al., 2005). There is a general concern about the lack
of a consistent approach to educational preparation,
scope of practice, and regulation (Francis, 2013;
Lintern, 2012; Sprinks, 2012; Willis, 2012). Regulation
would provide greater role clarity for nursing support
workers and other health care professionals, protect
the public from unsafe practices, and protect individual
support staff members from working beyond their scope
of practice (Storey, 2007).
Implications of Using Nursing
Support Workers
Introducing nursing support workers to a ward or unit
can be approached in one of two ways, either of which
can potentially change the mix of staff, approach to care
on a ward/unit, and impact on patients and staff. The
first is a substitutive model of nurse staffing, whereby
regulated staff (RNs) are replaced by unregulated nursing
support workers. This ultimately dilutes the skill mix
with fewer hours of care provided to patients by regu-
lated nursing staff (Blegen, Vaughn, & Vojir, 2008;
Roche et al., 2012). The second model is a supportive
or complementary model, whereby unregulated nursing
support workers are added to ward staffing. In this
model, the total number of hours of patient care pro-
vided increases, and the number of hours provided by
RNs is maintained (Carrigan, 2009; Roche et al., 2012).
Both methods have implications for the way patients are
assigned to caregivers and the work caregivers may then
undertake. Duffield, Roche, Diers, Catling-Paull, and
Blay (2010) found task assignment was used with a
poorer skill mix (fewer RNs) and when staff were
unfamiliar with the ward and patients. Patient allocation
was used when staffing included more RNs, more RNs
with degrees, and more expert nurses. Task assignment
can lead to issues with continuity of care because work is
divided into tasks and different staff members undertake
different tasks for the same patients. Usually, the RN
addresses more complex tasks, whereas lesser skilled
staff (nursing support workers) undertake more routine
tasks (Duffield et al., 2010).
There is growing concern that to meet current health
demands, the scope of nursing activities in which nursing
support workers are involved is expanding at a rate that
could potentially impact patient safety (Holloway &
McConigley, 2009), RN workload, and team efficiency.
One of the most significant and well-researched issues
related to their use is the impact on patient outcomes
(morbidity and mortality), particularly in a substitution
model. A number of large studies internationally have
found that a decreased use of RNs and an increased
use of nursing support workers result in high mortality
and morbidity rates and greater adverse patient out-
comes (Duffield et al., 2011; Kane et al., 2007;
Needleman et al., 2011; Roche et al., 2012). The state
of this body of work and science has now reached the
point where systematic reviews have been conducted. In
the first of these, Lang, Hodge, Olson, Romano, and
Kravitz (2004) reviewed 43 studies concluding a richer
nurse skill mix had a probable relationship with reduced
failure to rescue rates among surgical patients, and to
lower inpatient mortality rates and length of hospital
stay for medical patients. More recent studies link
reduced RN staffing with increased hospital-acquired
pneumonia, unplanned extubation, cardiac arrest, and
failure to rescue in surgical patients; longer length of
stay in intensive care units and surgical patients (Kane
et al., 2007); and increased mortality rates, between 2%
and 7% higher (Needleman et al., 2011). Failure to
rescue has been linked to nursing surveillance (Clarke
& Aiken, 2003; Kelly & Vincent, 2011), and RNs are
best qualified and able to accurately detect problems
and intervene in a timely and effective fashion (Clarke
& Aiken, 2003; Kelly & Vincent, 2011; Needleman,
Buerhaus, Stewart, Zelevinsky, & Mattke, 2006;
Tourangeau et al., 2007). Indeed, recent evidence sug-
gests that patient outcomes are even better where there
is a higher proportion of baccalaureate-prepared nurses
providing care (Aiken et al., 2011; Tourangeau et al.,
2007).
A change to unit staffing that includes the use of nur-
sing support workers also impacts on nurses with whom
they work (Marshall, 2006; Spilsbury et al., 2011). A
substitutive model of staffing that reduces RN hours of
care and increases those provided by nursing support
workers is likely to add to RN workload (Moyle,
Skinner, Rowe, & Gork, 2003), adds to the licensed
nurse’s responsibilities for ensuring patient safety
(Marshall, 2006), and leads to more interventions left
undone, poorer job satisfaction, reduced staff retention
(Aiken et al., 2001), higher rates of burnout (Leiter &
Laschinger, 2006), and increased costs linked to more
overtime claimed by RNs (Aiken, Clarke, Sloane, &
Sochalski, 2001; O’Brien-Pallas, Thomson, Alksnis, &
Bruce, 2001). In addition, RNs may spend less time
delivering bedside care, which can impact on their rela-
tionship with patients (Spilsbury & Meyer, 2005). There
is concern that when nursing support workers perform
aspects of patient care that have long been the province
of RNs, the lines and channels of accountability blur,
particularly if the role of the support worker is unclear
44 Policy, Politics, & Nursing Practice 15(1–2)
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(Castledine, 2004; Maben & Griffiths, 2008; Spilsbury
et al., 2011).
Researchers have also found that the expanding role
for nursing support workers can impact team efficiency
and patient care delivery. Feelings of role ambiguity and
role conflict from nurses toward support workers may
impede the functioning of the team (Keeney et al., 2005;
Spilsbury et al., 2011) and potentially increase the
responsibilities of RNs (Marshall, 2006). There is risk
of either an underutilization of support workers, irre-
spective of their skills, knowledge, or experience, or dele-
gation of tasks to support workers outside their
prescribed scope of practice, often with no RN supervi-
sion (Spilsbury & Meyer, 2005). Although RNs consider
themselves professionally accountable for the patient
care that they delegate to nursing support workers
(Alcorn & Topping, 2009; Marshall, 2006), many believe
that nursing support workers should also be accountable
for the care they deliver and, therefore, registered
with a professional, statutory, and regulatory body
(Alcorn & Topping, 2009). In addition, RNs are often
poorly prepared in the delegation, supervision, and
assessment of the competence of support workers
(Alcorn & Topping, 2009).
In contrast to the substitutive model, introducing nur-
sing support workers using a complementary staffing
model has been shown to have positive effects. Patient
rounding by RNs and nursing support workers, where
scheduled visits are made to patients in hospital rooms to
address immediate patient needs, has been associated
with positive patient outcomes and improved patient
safety (Blakely, Kroth, & Gregson, 2011), reduced
patient falls (Woodard, 2009), reduced use of the call
bell (Woodard, 2009), fewer work interruptions
(Shepard, 2013), consistency and continuity of patient
care, and improved patient satisfaction (Meade,
Bursell, & Ketelsen, 2006).
Need for Regulation
As nursing support workers represent a significant and
growing proportion of the health workforce, it is not
surprising that internationally the call for regulation
has been escalating (Storey, 2007). However, regulating
a new group of health workers is not a simple task. A
number of factors need to be considered including the
model of regulation to employ (e.g., voluntary vs. com-
pulsory, employer-led vs. statutory; Royal College of
Nursing, 2012; Storey, 2007), the cost to nursing support
workers who may earn significantly less money to nurses
(“How should HCA’s be regulated,” 2008), and deciding
which regulatory body is most suitable in overseeing this
group of workers (Storey, 2007).
Regulation of some categories of these workers cur-
rently exists. A number of U.S. states and territories
have primarily state-defined regulations or guidelines
for RN delegation, supervision, and assignment of nur-
sing support workers (i.e., unlicensed assistive person-
nel) in acute care hospitals along with mechanisms for
reporting their inappropriate use (Thomas, Barter, &
McLaughlin, 2000). Nonetheless, the scope of practice
of these workers varies from one jurisdiction to
another, and there are no standards for education and
training pertaining to them working in acute care U.S.
hospitals (Thomas et al., 2000). By comparison, the
United Kingdom has standardized, national vocational
training and duties for nursing support workers desig-
nated health care assistants (Thomas et al., 2000).
However, the Nursing and Midwifery Council does
not support mandatory regulation of health care assist-
ants; instead, it favors the development of delegation
standards for RNs and midwives and enhanced compe-
tency-based training for nursing support workers
(Commons Health Committee, 2012). Australia has
yet to mandate national, standardized vocational edu-
cation and training for nursing support workers who
can acquire skills through various pathways including
vocational training, informal training, and undergradu-
ate nursing programs (Algoso & Peters, 2012). The
onus currently is on employers in Australia to define
the essential functions, duties, and requisite competen-
cies of nursing support workers and on RNs to appro-
priately delegate, supervise, and assign work.
Continuing with the status quo—lack of regula-
tion—places the public, regulated nurses, and nursing
support workers at risk (Storey, 2007). Regulation
would provide consistency and perhaps greater account-
ability for nursing support workers.
Conclusion
Shortages in the nursing workforce and continuing
financial constraints are impacting the staffing deci-
sions of managers where supply and skill mix
become important considerations. However, it is unli-
kely that the escalating patient demands can be met
entirely by a workforce comprising RNs, leading to
the inevitable growth in employment of nursing sup-
port workers. The findings of inadequate nursing
care in the NHS are a signal to all countries that
changes in the composition of the health workforce
are underway with worrying consequences for
patients. For their protection, regulation of nursing
support workers must be given serious consideration.
More importantly, further research is required to
determine the positive impact that the addition of
nursing support workers (using a complementary
model) might have on patients and staff and
models of staff integration, which could possibly
maximize their use.
Duffield et al. 45
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Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This research work is supported by Australian Research
Council Linkage Grant (LP110200271).
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Author Biographies
Christine M. Duffield, PhD, MHP, BScN, RN, FACN,
FACHSM, FAAN, is Director of the Centre for Health
Services Management in the Faculty of Health,
University of Technology, Sydney (UTS). She is a pro-
fessor of nursing and health services management at
UTS and Edith Cowan University, Perth, Western
Australia. Professor Duffield has worked on many nur-
sing workforce projects nationally and internationally.
Di E. Twigg, PhD, MBA, BSc(Hons), RN, RM, FACN,
FACHSM, is a professor of nursing and Head of School
in the School of Nursing and Midwifery at Edith Cowan
University, Perth, Western Australia. She has had over
15 years’ experience in senior executive roles, primarily
as Executive Director of Nursing Services at Sir Charles
Gairdner Hospital. During this time, she led Sir Charles
Gairdner Hospital to become a Magnet designated hos-
pital. Professor Twigg has utilized her extensive leader-
ship experience in the development of research interests,
focusing on nursing workforce, patient outcomes, and
quality care.
Judith D. Pugh, PhD, MEd, PGradDipCurricEdTech,
RN, is a research associate at Edith Cowan University,
School of Nursing and Midwifery. She has extensive
experience as a registered and clinical nurse in intensive
care units across states in Australia. Dr Pugh has also
undertaken research projects in a variety of health-
related fields including nursing workforce and health ser-
vices research.
Gemma Evans, RN, BSc(Hons), is currently working at
Edith Cowan University as a research assistant in the
School of Nursing and Midwifery. Her research interests
include nursing workforce and retention. She has also
published work on registered nurse perceptions on nur-
sing research and the role of nurses in national safety and
quality health service standards.
Sofia Dimitrelis, MPhil, MPharm, BMedSci, works with
the Centre for Health Services Management in the
Faculty of Health at the University of Technology,
Sydney. In her role, she coordinates projects on nursing
workforce, turnover, and skill mix. Sofia is also a regis-
tered pharmacist with experience in clinical, research and
educational settings.
Michael A. Roche, PhD, RN, MHSc, BScN,
DipAppScN, is a senior lecturer at the Centre for
Health Services Management in the Faculty of Health,
University of Technology, Sydney. Dr Roche is a mental
health nurse with experience in clinical, educational,
information technology, and management positions in
the NSW public health system. He has been involved
in a number of research projects, investigating links
between the practice environment and outcomes for
nurses, patients, and the health system.
48 Policy, Politics, & Nursing Practice 15(1–2)
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