Introduction

The health care Iacilities all over the world are becoming more and more under exploration in
order to determine the cost eIIective as health care is becoming more and more labour intensive
and the need Ior more skilled and qualiIied are increasing. Even with the gradual increase in the
number oI nurses trained every year, there has been little improvement in the problems
associated with staII shortages and high cost. In order to overcome these problems and one oI the
methods they came up with was skill mixing.
Included in this essay is the over view oI skill mix and the skill mix cycle, and in this part skill
mix and how to use it is explained in detail. AIter the skill mix cycle, there is a review on the
approaches and limitations oI skill mix. AIter that the drivers oI the skill mix and the contextual
Iactors are looked upon. BeIore the conclusions, some recommendations has been added Ior the
methods that are used in Maldives. The aim oI the essay is to understand the basics about skill
mix and learn how to use it in real liIe or apply in real liIe situations in nursing, but this throry
can be used in any organizations or workplace. This essay illustrates the Iactors than can aIIect
skill mix and the opportunities and barriers.
LasL buL noL Lhe leasL sLep ls decldlng Lhe besL approach Lo sklll mlx 1he dlfferenL approaches uslng over
Lhe world ls explalned afLer Lhls parL Careful Lhlnklng and plannlng ls Lhe besL way Lo deLermlne
accordlng Lo whaL ls Lhe besL and mosL efflclenL approach for LhaL work place ln LhaL slLuaLlon lL ls
posslble Lo seL shorL Lerm and long Lerm goals accordlng Lo person's wlsh And ln sklll mlx Lhe approach
chosen wlll declde lf Lhe changes wlll be broughL over long Lerm or shorL Lerm 1he meLhods of approach
may vary from slLuaLlon Lo slLuaLlon lor example Lhe meLhod of approach for one slngle ward may be
dlfferenL from Lhe meLhod of approach for Lhe whole hosplLal 1he chosen meLhods and approach musL
have Lhe capaclLy and ablllLy Lo brlng abouL Lhe changes ln Lhls sLage Lhe acLual changes ls made and
afLer Lhls lL goes back Lo sLep 1 LhaL ls evaluaLlng Lhe problem ln whlch Lhe resulLs of Lhe change
broughL abouL ls analyzed and scruLlnlzed closely and furLher ad[usLmenLs are made and Lhe cycle goes
on conLlnuously
Approaches and ||m|tat|ons to sk||| m|x
klll mlx can be analyzed ln any organlzaLlonal groups (vargos Lagos 1991 8hopal 1994) Approaches
Lo sklll mlx can be dlvlded lnLo Lwo maln parLs quallLaLlve and quanLlLaLlve approaches CurrenLly Lhere
are elghL dlfferenL approaches used all over Lhe world Lo revlew and deLermlne sklll mlx 1here has been
many researches conducLed all over Lhe world Lo prove whaL sLraLegy or sLrucLure ls Lo be followed ln
order Lo deLermlne Lhe besL mlx of sLaff for work places
1he flrsL approach meLhod ls Lask analysls and ln Lhls meLhod Lhe frequency cosLs skllls and knowledge
needed for lndlvldual Lasks are analyzed 1hls meLhod ls also used Lo [udge Lhe sLaff quallLy and ldenLlfy
Lhe holes ln Lhe sysLem 8uL Lhls meLhod ls cosLly and based on Lhe Lasks only AcLlvlLy analysls ls Lhe
nexL approach and ln Lhls approach Lhe acLlvlLles done by sLaff are supervlsed for Lhe sklll and Llme
managemenL and recorded and used Lo allocaLe acLlvlLles nexL Llme 1he dlsadvanLages of Lhls meLhod ls
LhaL havlng supervlsors Lo monlLor each and every Lask ls expenslve and use of Lhls meLhods ln wards
where Lhere ls no flxed sLaff or sLaffs who roLaLe all around Lhe very slmllar Lo acLlvlLy analysls 1he only
dlfference ls Lhe Lasks wlll be monlLored by Lhe sLaffs Lhose who do lL lnsLead of a supervlsor Lven
Lhough Lhls meLhod ls cheap Lhere ls hlgh chance LhaL Lhe lnformaLlon provlded by Lhe sLaff abouL
Lhemselves mlghL be accuraLe
lourLh meLhod ls case mlx or paLlenL dependency aLlenLs are dlvlded lnLo groups accordlng Lo Lhelr
dlagnosls and a formula ls used measure Lhe hours of work requlred by each sLaff 1hls meLhod ls a mlx
of boLh quallLaLlve and quanLlLaLlve meLhod Cne advanLage of Lhls meLhod ls LhaL lL ls posslble Lo
deLermlne changes LhaL are needed Lo brlng Lo maLch Lhe changlng demands of Lhe place AnoLher
meLhod ls reproflllng (zero based) meLhod ln whlch Lhe currenL mlx acLlvlLles skllls cosLs are closely
analyzed and work force flnds meLhods wlLhln Lhe avallable resources buL Lhls meLhod ls rarely applled
even Lhough lL ls radlcal and fundamenLal because of organlzaLlonal and pollLlcal barrlers rofesslonal
[udgmenL ls yeL anoLher meLhod ln Lhls meLhod Lhe managemenL assess and analyses Lhe currenL
condlLlon of Lhe work place and

















Skill mix in theory
This part oI the essay is mainly based on what skill mix really is and the detailed explanation on
skill mix. 'Skill mix is the various levels oI health staII required, either within a particular
discipline or Ior the staII within a health care system to provide eIIicient care, not just a technical
exercise(nursing dictionary 2011). 'It is the range oI diIIerent skills possessed by the memories
oI a group or required Ior a particular job (medical glossary 2011). In other words skill mix is
the mix oI diIIerent levels oI staIIs (in this case it is the nurses) to create the most cost eIIective
work place where the best quality care can be given. Another name Ior skill mix is the personnel
mix. Overall skill mix is a topic that is very broad and it has many meanings, the mix oI
employees in those posts or the levels and various skills that comes with each individual.

The skill mix cycle
Like most oI the processes, skill mix is an ongoing process to achieve the best mix oI skills. It is
important to choose the right method and to help choose the most eIIicient method, this cycle can
be used. The Iour main parts oI skill mix are planning Ior change or assessing resources.
IdentiIying opportunities and barriers Ior change or measuring the span oI control, evaluating the
need Ior change or deIining the problem and making the change happen. (Buchan J,et al,2000).
The Iirst step oI the skill mix cycle is evaluating the need Ior change. For every answer in the
world there is a question, thus it will not be oI any help even iI the problem is not clear or
unknown, even iI skill mix is the answer or solution to what problem. So in this stage the
problem is evaluated and it is analyzed and calculated iI it is necessary to bring about any
change. II the need Ior change arises then the extent oI change and the speciIic changes must
start is decided. In other words a goal is set and the plane is made in this stage on what must be
done or what methods are to be chosen in order to bring about the most eIIective changes. The
needs and number oI patients and staIIs, plus the daily tasks and quality oI care must be kept in
mind when planning. In addition to this the possibility that another much better solution to the
problem may exist is there. To overcome this, the Iirst thing to be done beIore planning is to
analyze and research on the problems and the solutions, as this can help to Iind the method that is
best Ior the current problem and reduces the chances oI worsening the problem.
The second step is understanding the extent oI control and power the person has. Does the person
has enough power and control that is required to bring about the changes required. For example a
nurse may want to change the policy about obeying the rules and regulations in a ward, but no
matter how eIIicient or good it will be iI the changes planned by the nurse is, it is not possible to
bring about the changes because she does not have the power to do it. Likewise in all the
organization, the level and extent oI power held by people in diIIerent levels are diIIerent. A
person who is in a more senior level will have more power than someone who is junior. The
purpose oI this step is to decide changes that are eIIicient and within the control span, because no
matter how good the changes are in theory, it will not be oI any use in reality. Some Iactors in
this stage include Iinance, resource, legislative and regulatory constrains. When the changes are
being determined it is important to keep the above Iactors in mind and decide changes that is
within the power oI that person.
The third step is assessing and analyzing the resources that is there and the available resources .
Resources is another Iactor without which the changes to be brought about will be incomplete or
cannot change at all. DiIIerent approaches to skill mix require diIIerent level oI resources,staII ,
skills,training, knowledge and inIormation. Availability oI resources and span oI control are two
thing without which the eIIicient changes cannot be brought about, so as written earlier , the
change needs to be within the available resources. Resources and span oI control can provide
apportunities or barriers according to the availability or unavailability. This is why the problem
needs to be analysed and planned very careIully.

Review the data available and make judgments. Barriers to this method include unclear
objectives, and possibility that big or drastic changes may be diIIicult to bring about.
The last two methods are job analysis interview or group discussion. In job analysis interview or
role reviews individuals or group interview are taken that are very detailed. It can include critical
incident technique or repertory grid. This is a structured approach in iI the interviewers have the
skill, a lot oI important interviews can be withdrawn Irom each individual or groups. The main
disadvsantages oI this method are lack oI objectivities and potentials Ior hias. Last method group
discussion brainstorming` is about group oI staIIs holding group discussions or seminars about
the problems that need to be solved and in this method the available data is used as the topic oI
discussions. This method is Iast and commonly used to Iind out what is wrong. This method
requires skilled people, raises expectation and can be used to gather a lot oI inIormation.
The research held by WHO analyzed skill cost eIIectiveness (Buchan, Ball and O`May, 1996).
473 publications were identiIied and some oI the main limitations oI this method include
inaccurate and incomplete reports and various chinks in the methods. Most oI the studies did not
show reasons why that method was chosen, and gives little inIormation on what evidence the
discussions were made. Another reason was most studies do not provide appropriate evaluations
oI quality cost and outcome.
Skill mixed in context
Researchers were conducted in diIIerent hospitals oI the world including Costa Rica, Finland,
Mexico, United Kingdom, and United states. These countries were chosen because they were
using diIIerent models in their hospitals. Two main questions were asked, 'Why do health care
providers embrace on a skill mix exercise`? What are the drivers? And how do they decide what
to do?
ontextua| factors
1he conLexLual facLors can affecL sklll mlx vlewers along wlLh addlLlon Lo shaplng reasons for sklll mlx
1he presence of cerLaln conLexLual characLerlsLlcs deflnes Lhe exLenL of posslble change ome of Lhe
dlrecL and lndlrecL conLexLual facLors lnclude pay sLrucLures (naLlonal or local) AredlLaLlon of employer
organlzaLlons professlonal auLonomy exLernal budgeL seLLlng fundlng (allocaLlon Lo publlc and prlvaLe
healLh care sysLems general economlc slLuaLlon socleLal values of roles of employmenL / [obs
1he resulLs of Lhe research showed LhaL Lhe exLenL Lo whlch sklll mlx can be alLered locally lL unlLed
LaLes shows Lhe mosL apparenL resulLs ln oLher counLrles such as Mexlco and CosLa 8lca where Lhere
has been less decenLrallzaLlon of on budgeLs and declslon maklng wlLh Lhe publlc secLor healLh
sysLems"
Recommendations
Here in Maldives, the method seen most often is patient allocation. The nurse will be allocated
to a group of patients or an individual patient, and that nurses required doing all the tasks and
caring for that patient for this the nurse needs to be very skilled and there is always shortage of
skilled nurses even though there are many less skilled nurses without jobs. t will be cheaper
and more efficient if the less skilled nurses are hired to do the simple tasks such as bed bath,
offering bed pan and feeding etc. this time will be left for more skilled nurses to plane and carry
out more advanced care. The demand for skilled nurses will than decrease.
Attendants can be trained to empty urine bags without contaminating or introducing micro
organisms into the bag or catheter tube. They can also be taught how to calculate the strength
of the chemicals, to dilute them and the concentrations to be used to clean different substance.
t can also be useful if there is a continuous supervisor to monitor if the nurses are doing
procedure accordingly. Tests can be held for all nurses to test their knowledge every once in a
while.
A team can be made within the ward to take decisions in the ward. Another method is to
allocate tasks and divide them among staffs. Different staffs get different tasks every day.
Senior nurses can teach juniors and how to improve their skills.

oncIusion
Skill mix in nursing is the mix of different levels of nurses to work together to create cost
effective and efficient work place. The type of skill required is determined with the help of a skill
mix cycle consisting of four main parts. They are planning for change, identifying opportunities
and barriers, evaluating the need for change and making the change happen.
The outcome of skill mix is determined by the approach. There are about eight methods of
approach used all over the world. Before applying skill mix there needs to be a lot of information
about the current situation and a very big limitation to skill mix is getting inaccurate. Overall
there are many factors that can affect skill mix such as drivers and contextual factors. Skill mix
can be used in any organization and modified to any situation.