The first step to safely change the nursing skill mix is to determine the appropriate proportion of RNs and support staff.

There are three factors nurse leaders should consider:

1. Benchmarks – Average skill mix levels of comparable units can provide guidance on appropriate range for proportion of RNs
2. Unit-specific attributes – Unit-specific characteristics, including patient acuity and ADT1, can impact appropriate proportion of RNs
3. Support staff skill level – Support staff can have various levels of educational preparation, training, and certification; units with less-skilled support staff may need higher proportion of RNs

To determine the appropriate proportion of RNs and support staff, nurse leaders at Inova used computer simulation software. The software allowed them to test the effects of different inputs—including the number of patients on the unit, staffing mix and skill level—on the unit’s outputs, such as nursing labor cost and value-added time. After testing 129 scenarios, leaders at Inova determined the skill mix that resulted in the most favorable outcomes.

After completing their computer modeling, leaders at Inova reduced the system-wide average nursing skill mix from 82% RNs to 70% RNs. Inova’s inpatient nursing care teams are now comprised of three roles: one RN, clinical tech 2 (LPN), and a clinical tech 1 (unlicensed assistive personnel). Each care team member is accountable for specific patient care responsibilities.

Key responsibilities for each of Inova’s inpatient nursing roles are shown here:

While it is important to clarify exactly what each individual is responsible for, it is equally important to clarify what each individual is not responsible for. At Inova, nurse leaders determined that medication administration should not always be the primary responsibility of the RN. On some units, medication administration is now performed by clinical tech 2s, or LPNs. Leaders at Inova attribute part of their success to the specialized training on medication administration they provide to LPNs.

Reinforce the appropriate scope for each team member by clarifying caregiver roles to both patients and staff. At Inova, RNs, clinical tech 1s and clinical tech 2s each wear different scrub colors. Inova also uses a different title for LPNs. Formally calling them “clinical tech 2s” helps prevent team members and patients from confusing them with RNs. There are four additional ways to clarify roles, listed below.

1. Title– Use a different title to refer to LPNs to reinforce that they are not RNs.
   
   
2. Standardized introductions – Nursing team members share their name, title, and patient care responsibilities when they introduce themselves to patients and families.
   
   
3. ID badge – Clearly designate role on each ID badge, with a color-coded band corresponding to each role.
   
   
4. Scrub color – Determine a unique, standard scrub color across the organization for each nursing role.

The third step is to train nursing staff to safely deliver care as a team. Inova’s training has two key components. The first component is role-specific training. For example, clinical techs attend a mandatory three-week Clinical Technician Academy before starting work. Clinical tech 2s receive training for advanced skills, and RNs receive additional training on team management and delegation.

The second component is a demonstrated skill sign-off process for clinical techs. Leaders at Inova ensure support staff are competent and that RNs can trust them to safely perform delegated work. Inova uses a rigorous skill sign-off process for key responsibilities, including blood draws, IV insertions, and urinary catheter insertions, to ensure clinical techs can demonstrate a minimum competency level. For example, to demonstrate blood draw competence at Inova, clinical techs are required to successfully perform 50 blood collections under supervision before they can perform them independently.

The fourth step is to gradually phase in changes over many years. The timeline shown here depicts Inova’s gradual transition to their target skill mix. Notably, no RNs at Inova were laid off to achieve this new skill mix. Instead, when RN positions opened due to natural turnover, nurse leaders deliberately did not backfill all RN positions.