Balancing Workforce Challenges and Increasing Care Complexity

Ask any manager, and achieving the right skill mix in healthcare teams is one of the most challenging aspects of leading a clinical care-facing team. Getting the right skill mix is essential to quality and safe patient outcomes. If that task wasn’t already critical to the care provided, team culture, morale, and staff satisfaction, it just got more critical and harder!

This is because we currently grapple with a decline in the experience of the healthcare workforce and an increase in the complexity of care. Effective skill mix management and thoughtful staff allocation are key to navigating this challenge, referred to as the experience-complexity gap.

Striking the Right Balance: Quantity and Quality

The delicate balance we need to juggle is ensuring enough staff to meet patient numbers (quantity) and having the right skill set and mix of experience (quality) to care for patients safely. Most critically, this is a constantly evolving situation. Patient numbers fluctuate throughout a shift, new admissions occur, and patients' conditions can deteriorate, rapidly increasing the complexity of care.

In an ideal setting, nurse-to-patient ratios are predictable and stable, and they solve most issues: one nurse for four patients (in a non-high-acuity area). However, the reality is far more nuanced. Effective skill mix management is about more than just numbers; it’s about matching staff strengths and experience with the needs of each patient.

To achieve this balance, it’s essential to know your team's individual skills, capabilities, and opportunities for growth. From there, we can make informed decisions when matching staff to patient complexity.

Know Your Novice Staff

Not all novice or graduate nurses have the same capabilities, and we cannot assume their competence or confidence based solely on their pay grade. Assuming uniform skill levels can lead to inefficiencies, errors, harm and missed growth opportunities.

I prioritised meeting regularly with my early-career nurses and graduates to understand their clinical competence and confidence. This approach helped me manage a high-risk group in a high-risk intensive care unit (ICU) and allowed me to build rapport early.

For example, some nurses thrived in the fast-paced, high-pressure environment of post-operative cardiothoracic cases. For these individuals, I would allocate them (within their scope of practice) to work alongside an experienced clinician receiving such a patient. This gave them valuable exposure while ensuring they had the necessary support.

Others preferred the continuity of care provided to longer-term patients without complex ICU attachments like ventilators or renal replacement therapy. These nurses excelled in providing compassionate care, offering patients high-quality personal care and meaningful interactions that benefited both the patients and their families.

Create a Staff Capability Matrix

A staff capability matrix became an essential tool for me. It was a live document that essentially documented the skills, competence and support needed by all staff in the ICU where I worked.

Tracking and organising team members' competence, not just grades (e.g., RN Grade 2), allowed managers, educators, and senior staff to make evidence-based decisions about staff allocation. It was helpful when a new staff member was unexpectedly in charge and helped with succession planning. The tool also supported targeted training, helping me guide staff towards skill progression and knowing which areas to prioritise competency development in.

Name	Qualification	Capability	Level of Competence	Support Needed / Notes
Jane Doe	RN, Graduate Certification (Intensive Care)	Pacing wire management	Fully competent	None
		Intercostal catheter care	Fully competent	None
John Smith	RN	Pacing wire management	Requires supervision	Support from CNE
Sarah Brown	Graduate RN	Intercostal catheter care	Limited exposure	Buddy with senior nurse
		Post-op mobility assistance	Fully competent	None

Key Features:

• Documents qualifications (including any additional certifications).
• Records team members' skills and identifies strengths or gaps.
• Highlights support needs for safer patient allocation.

The Juggle is Real: Day in the Life of a NUM

How would I navigate acuity and skill mix and appropriately allocate staff to patients? I’d focus on planning and knowing the situation could change throughout the shift.

1. Assess and Allocate Staff

As a nurse unit manager (NUM), I assessed the team roster at the start of each shift and cross-checked this with my staff's skill levels. During handover, I reviewed the patient demographics, case complexity, and anticipated admissions, mostly surgical lists (but of course, there was always the potential for unplanned admissions from deteriorating patients).

From there, I strategically allocated patients to balance staff skill sets with patient safety.

If possible, experienced nurses were assigned complex or critical patients, while more novice nurses were paired with lighter patient loads—but ideally placed geographically close to senior colleagues. This allowed new nurses to consolidate time management skills and gain exposure to complex cases in a safe, supportive way, but also support with higher loads.

I always ensured my team understood the rationale behind these decisions. I tried to set the tone for collaboration and reassured staff that they were supported, even during challenging shifts.

During handover, I might say:

2. Proactive Problem-Solving

Beyond allocation at the start of a shift, being proactive was critical to managing complex shifts. If I anticipated heavy post-operative admissions, I would contact the theatre manager early to communicate our capacity and pressures. This ensured we could pace incoming patients and avoid overwhelming the team.

For example, during a particularly challenging shift with multiple deteriorating patients, I communicated early with the theatre manager to delay incoming admissions slightly. This gave us time to stabilise the ward and ensured the team could prioritise critical care without feeling overwhelmed, leading to better patient and staff outcomes.

I always considered the situation holistically, balancing staff capabilities, patient needs, and broader hospital priorities, such as deteriorating patients requiring ICU admission. Transparent communication and forward planning allowed us to manage complex shifts safely and effectively.

Strong Leadership and Culture

While immediate staffing solutions often focus on quick fixes, I believe the long-term answer lies in strong leadership and a supportive culture prioritising staff development and retention.

By systematically tracking skills through tools like a capability matrix, I could identify areas for targeted training and ensure novice nurses gained exposure to critical competencies and situations under supervision. Encouraging experienced nurses to mentor junior staff transferred skills and built team cohesion and morale.

We can create resilient, future-ready teams by thoughtfully allocating staff to patient needs, balancing safety with growth opportunities, and building a culture of collaboration and learning.

Conclusion

Effective skill mix management is one of the most difficult tasks I have encountered as a manager. Nowadays, as workforce shortages and the complexity of care increase, it is only getting more difficult. Whilst we will always be limited by the number of staff available to us and the team's current skills on the given day, I genuinely believe the key lies in understanding your team’s capabilities, using tools like a capability matrix, and fostering proactive leadership.

References

BMJ Quality & Safety 2017, 'Improving quality and safety of care', BMJ Quality & Safety, vol. 26, no. 7, pp. 525-531, viewed 18 December 2024, https://qualitysafety.bmj.com/content/26/7/525.

Alvarez, G. & Fitzpatrick, J.J. 2018, 'Nurses’ job satisfaction and patient care', BMC Health Services Research, vol. 18, no. 204, viewed 18 December 2024, https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3812-4.

Buchan, J., O'May, F. & Ball, J. 2017, 'Skill mix changes: What evidence on patient outcomes and health systems?', in Skill-Mix Innovation, Effectiveness, and Implementation, Cambridge University Press, pp. 134-151, viewed 18 December 2024, https://www.cambridge.org/core/books/skillmix-innovation-effectiveness-and-implementation/skillmix-changes-what-evidence-on-patient-outcomes-and-health-systems/E14E23B4D28A3DC1AED8E7694D6BD7D9.

Leigh, J.P., Tancredi, D.J. & Kravitz, R.L. 2009, 'Physician workforce needs in the United States', Human Resources for Health, vol. 7, no. 87, viewed 18 December 2024, https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-7-87.

Smith, R. & Patel, K. 2024, 'Public health challenges in the 21st century', Frontiers in Public Health, vol. 12, article 1448871, viewed 18 December 2024, https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2024.1448871/full?.

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