Academic journal article Bulletin of the World Health Organization

Skill Mix in the Health Care Workforce: Reviewing the Evidence

Academic journal article Bulletin of the World Health Organization

Skill Mix in the Health Care Workforce: Reviewing the Evidence

Article excerpt

Introduction

The World Health Report 2000 noted that determining and achieving the "right" mix of health personnel are major challenges for most health care organizations and health systems (1). Health care is labour-intensive and managers of health care provider units strive to identify the most effective mix of staff that can be achieved with the available resources, taking into consideration local priorities.

The term "skill mix" is usually used to describe the mix of posts, grades or occupations in an organization (strictly speaking, this is more accurately referred to as "grade mix"). It may also refer to the combinations of activities or skills needed for each job within the organization. This paper gives a brief overview of the determining factors that should be taken into consideration when assessing and adjusting skill mix. It then summarizes the main findings from a literature review, highlighting the evidence on skill mix that is available to inform health system managers, health professionals, health policymakers and other stakeholders.

There is no common starting point for examining skill mix in different countries, sectors and health systems. Resource availability, regulatory environments, culture, custom and practice will all have played a role in determining the typical or normal mix of staff in a particular health system. To the extent that these factors Vary, so will the typical mix. Indeed there are marked variations between countries and regions in terms of the mix of health care occupations (2). Table 1 highlights some of the key considerations that explain why skill mix is important in many health systems (3).

The factors that generate pressure for change in the skill mix are not mutually exclusive, and changing the skill mix is not the only option for responding to them. Employing organizations should also review other possibilities, such as improving the use of hospital beds, capital equipment and other resources; improving staffing patterns in relation to day-to-day fluctuations in workload and patient dependency; and adjusting the distribution of resources (e.g. between tertiary, secondary and primary care).

Reviewing skill mix

Our review of publications examining skill mix in health care was based on two literature searches. The first was undertaken for the World Health Organization (WHO), and focused on English-language material published between 1986 and 1996 found through CINAHL, Medline, RCN Nurse ROM, ASSIA Plus, and FirstSearch (4). The second comprised a follow-up search of English-language material published in the period 1996-2000 through CINAHL, Medline, ASSIA and Nurse Online. The search terms used were: "skill mix", "skill substitution", "personnel mix", "reprofiling", "staffing levels", and "staffing mix". The term "changing roles" was also included for the second search.

The review indicated a growing interest in skill mix, with more than twice as many publications recorded for the period 1996-2000 as for the previous 10 years (1986-96). The main findings are grouped as follows: reviews and meta-analyses; large-scale ("macro") data surveys; single-site ("micro") examinations of roles and mix in nursing and other non-medical health professions; single-site ("micro") examinations of role overlap between doctors and other health professionals; and studies on introductions of new types of worker.

There are several limitations to the review. First, there may be publication bias, because unsuccessful attempts at changing skill mix may be less likely to be recorded and published. Second, searches rely on the use of key words; skill mix is covered by a broad range of possible key words, and some relevant publications may have been missed. Third, most of the publications reviewed are in English; this will lead to bias in terms of the countries and health systems being examined. In particular, the majority of the publications are from the USA, where the health system is predominantly in the private sector and there is a free-market approach to employment legislation and job stability. …

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