Nursing Skills Impact on Professional Development

Subject: Nursing
Pages: 65
Words: 17715
Reading time:
59 min
Study level: College


In workplaces today, individuals are endowed with various skills. These skills can be used together to perform a particular function or job. The role of skill mix in transferability of skills and knowledge in community nursing context has been highly debated among different stakeholders (Richardson et al., 1998). While many agree that having differently skilled nurses working together allows transfer of skills, some argue that this method of skill mix could erode quality of professionalism.

Proponents further argue that skill mix allows community nurses to accomplish their duties more effectively by having different skills available on site. It further allows better quality of results when nurses with different skills can specialize in the area in which they are good at. It also allows them to train and learn new skills from each other to ensure they stay relevant in the industry. By so doing, they are further able to deliver better quality and perform more duties.

The current research proposal will focus on community nursing and how skill mix allows the development of skills. It will focus on the role of nursing skill mix on transferability of skills and knowledge among registered nurses working in the community nursing context. The area of implementation for the paper is North Batinah Region in Oman. Professional development in this paper will address administering medical services, having proper professional ethics, and being able to execute professional duties in a skilled manner.

This research proposal highlights methods that will be used to collect primary and secondary data. In preparation for that, it analyzes literature on the different aspects surrounding skill mix. These include skill mix and quality, and the role of nursing skill mix in ensuring professional development in the healthcare sector.


The materials being used in the current research study have been obtained from diverse sources that include peer review articles, books, academic journals, online articles, past projects by different authors, statistics from government and non-governmental organizations on skill in the healthcare sector. The literature materials and sources used for the current study are important for reasons that include verifiability of facts, to challenge opinions and facts, and to provide quotations. Importantly, the research strategy of using the aforementioned materials aims at reinforcing multiple points of view from different authors, their opinions on the subject and their prevalent positions.

To begin with, Richards et al. (2000) defines skill mix diverse skills or abilities to be used to perform a particular function that an individual or a group possesses. The role of skill mix in transferability of skills and knowledge has been a source of debate in the healthcare industry for a long time now. He further argues that skill mix in health care is important since it potentially contributes to a health workforce that is effective and efficient (Richardson et al., 1998). This is evident from the levels of implementation of skill mix initiatives that have taken place in different countries. Among the countries that take skill mix seriously is Russia, Spain, Russia and the United Kingdom.

The role of skill mix in professional development in community nursing context is driven by different factors and considerations. According to Bluestone, 2006, desirability and change of direction are some of the factors that have caused significant differences in ratios of nurses and physicians in the Organization for Economic Cooperation and Development (OCED) countries. Conelly and Banham (2002) explain that changes and strategies utilized further depend of different factors. They further exemplify that there are diverse motives that prompts healthcare agencies to implement skill mix. These motives include the need to improve the level of professionalism, for quality improvement, to cover for shortages of particular categories of workers in rural areas or in the cities and for service innovation.

Professional development can be defined as the knowledge and skills that an individual acquires for the advancement of career and for self development (Speck and Knipe, 2005). In a community or group context, it involves engaging shared learning and having a team that is working towards common objectives. Community nursing on the other hand is a role taken by healthcare organization to work with families, individuals and communities to create awareness on healthy lifestyles, safety, and to help maintain independence of patients, offer support, treat existing health problems, maintaining health and preventing diseases (HealthInsite, 2011).

According to Benner (2001), the practice skill mix in nursing has drawn both support and opposition from different quarters. This has caused a division between health care professionals and managers of the National Health Service (NHS). If this is to be done in the community nursing sector, the threat of losing quality in that sector would be more real. Such a measure would also lead to the erosion of value for quality. As Blank and Burau (2007) explains, health care professionals have been gripped with fear that skill mix in the health sector will erode it of quality. Additionally, the trade unions observe that skill mix creates a spectrum of redundancy. The debate over the issue of skill mix in community nursing continues to heighten and more issues keep arising. For example, arguments between professional community nurses and other stakeholders over what should be done have resulted in a belief that only community nurses can comprehend the complexity of their skills (Joint Commission on Accreditation of Health Care Organizations, 2005). They therefore argue that they should be allowed to make all the decisions that affect how they implement initiatives such as skill mix and its role in professional development.

According to Borbasi and Gaston (2002), skill mix plays an important role of development in nursing practice. Some of those roles include innovation, enhancement of skills in delegation of roles up and down a uni-discplinary ladder and substitution between different groups. In the context of community nursing, several simplistic approaches to the issue of skill mix in the past have not done much to allay the confusion and disagreements (Moram, 1999). When skill allocation is in such a way that it only allows nurses to do what they have been trained to do, the possibility of skill redundancy is real (London Department of Health, 2002).

It is for this reason that skill mix initiatives are implemented. Having a group of differently skilled nurses working together allows them to learn from each other, and transfer skills they have perfected in to the rest of the team. Since communities have many changing needs, having nurses whose skills are constantly updated is only possible by having them interact with different skills regularly. As Wrede (2008) argues, meeting the health needs of local populations and giving adequate and efficient health services can be appropriately aligned if careful consideration is put on skill mix.

Having a team that shares common objectives for the process they are engaged in makes it possible for them to extract skills that are useful in their line of duties from their team mates, and use them to expand their knowledge (Marriner-Tomey, 1993).

Cribb (2005) argues that skill mix in nursing is important in any case a health care wants to maneuver when a staff quits. Indeed, this is true since low staff turnover and the culture of long service in healthcare organizations exist (Cribb 2005). Therefore, there is need for such organizations to create room for development of skill mix among the existing workforce. It is important to realize that skill mix works by ensuring that each staff member has a unique cluster of skills, a very significant factor in the completion and success of various team works (Chen et al., 2004). Skill mix can be used as encouragement to have community nurses expand the scope of their skills and knowledge, and develop different styles that suit the current medical needs in communities (Ministry of Social Affairs and Health, 2002). When skills are properly nurtured and developed, it is easier for them to accomplish different duties and monitor them accurately (Shumbusho, et al., 2009).

Statement of the problem

The community nursing sector is today faced with many challenges that make it hard to deliver quality and do it consistently (Parle, Ross and Doe, 2006). Key among these challenges is professional development. There are constant disputes over roles and responsibilities between senior and junior nurses, and other medical professionals, perhaps from the lack of constant initiatives to upgrade skills and adjust roles (American Association of Colleges of Nursing, 2011). The complexity of the community nursing profession makes it hard for governments to intervene wherever professional related challenges arise. This stems from the reason that the management of hospital feels adequately able to tackle pertinent issues (Cribb 2005).

Reports from the Gallup Organization (2000, p. 1), “established that nurses have continued to show tremendous improvements in ethics and in it maintained a high standard of honesty. Ten years later, the industry faces major challenges as far as ethics and discipline are concerned. The healthcare industry is faced with challenges that come with the constant changes happening in the industry. More cases of questionable conduct are filed each day and ethical concerns and issues are still evident (Constable & Russell 1986).

Regulations, policies and expectations from patients may sometimes be hard for community nurses to keep up (Rese et al., 2005). In order to ensure that community nurses still hold that position they held a few years back, it is necessary that they have initiatives and someone to help them constantly update their skills and mold their characteristics.

In Oman there is a clear policy that there is no direct recruitment in primary health care institutions. Each nurse has to work in cute practice for at least 2 years and then he or she can apply to transfer for primary health care context (Ministry of Social Affairs and Health, 2002). Therefore, preparing nurses to work in the community context is a good and powerful method to overcome the lack of in educational preparation (Dyess & Sherman 2009). The North Baterina region established a policy to assign nurses shift work based on their years of experience, skills and qualifications (Appendix 1). The aim of this policy was to provide good environment for transmission of knowledge and skills between nurses working in primary health care institutions. In addition, the nursing leaders in the region in coordination with staff development section involve those senior nurses in programs called master trainers program and training of trainers (Appendix 2). This is to provide them with background about effective way of skill and knowledge transformation

The current research proposal will focus on community nursing and how skill mix allows the development of skills. It will focus on the role of nursing skill mix on transferability of skills and knowledge among registered nurses working in the community nursing context. Additionally, it will study how nurses are assigned with special roles, skills and qualities to match the patients’ needs. For instance, nurses with tissue viability skills will care for and educate clients with bed sores, diabetic foot. Moreover, it will seek to determine whether junior nurses will be accompanied by an experienced nurse. This study will take place in North Batinah Region in Oman. Professional development in this paper will address administering nursing services, having proper professional ethics, and being able to execute professional duties in a skilled manner.


To explore the role of skill mix in transferability of skills and knowledge among registered nurses working in a community in North Batinah Region in Oman.


  • To critically review the literature in order to evaluate the impact of nursing skill mix on professional development and transferability of skills and knowledge among registered nurses specifically in community nursing
  • To evaluate the role of skill mix and how nurses participating in nursing professional development and practice can apply it effectively and efficiently to offer health care services.


The current research proposal on the impact of nursing skill mix on professional development targets meeting the lack of enough workforce in nursing practice. Having considered the results, it will be possible to state whether skill mix plays a vital role in nursing professional development and its impacts in nursing practice. The results will be used to explain different responsibilities of skill mix and how they contribute to the health care’s development. The influence of skill mix is evident in its role in training, coaching and development (Dyess & Sherman 2009). One of the problems that would rise would include policies against transferability of skills among nurses. The possible solution will include health professionals understanding the benefits of skill mix in providing adequate and effective healthcare services.

Skill mix and key issues

As Constable and Russell (1986) explains, the implementation of skill mix in an organization has immense benefits that include incorporation of procedures and processes with aspects that rewards professionals. Skill mix help professionals to create performance and ensure benefits, design structures and maintain structures, measure job values and track new skills. However, it is important to note that skill mix management is not just about skill development. It is also about quality performances which boost confidence in the industry, and improve employee’s confidence as well as motivation. Key issues to address in skill mix in the community nursing sector are;

  • How to ensure external and internal competitiveness and equity
  • How to reward community nurses as individuals and promote team work as well
  • Which skill mix management processes are appropriate for the community nursing sector
  • How to devolve power and ensure nurses can manage their own skill mix strategies while staying within the sector’s policies
  • How to motivate those community nurses who have reached the highest level of career possible in the sector
  • How to ensure skill mix initiatives translate to improved performance
  • How to structure and design skills evaluation schemes
  • How to ensure community nurses are prepared for both their inputs and outputs
  • How to make community nurses recognize and appreciate skill mix as a positive technique in the healthcare sector

In today’s scenario, there are various skill mix trends available for the community nursing sector (Rechel and Dubois, 2006). As Armstrong, Duncan and Peter (2010, p. 100) explains that there is need for organizations to develop strategies that will create greater role flexibility and that will ensure they adapt to new organizational developments. They further claim that this has been a trend that most industries in the world today have adopted and use it to manage relatives by creating awareness on job measurement. Others choose skill mix structures that cover every employee regardless of their position. Team pay is a common trend in any industry trying to introduce new initiatives in their sector (Hughes, 2004). Other trends include performance awards and more sensitivity to functional markets to enable the sector to retain talented employees.

Literature review

One of the biggest challenges facing the nursing profession today is shortages, skill development and changing demands and medical needs. It is also the drive behind many other strategies and initiatives being implemented in the sector. These challenges demand initiatives that will ensure constantly updated skills, well trained and professionally developed community nurses (Dyess & Sherman 2009).

To understand transferability of skills and knowledge as a professional development technique, Cheng (1998) explains the concept and its applicability in graduates. The author explains that transfer of skills is beneficial in an organization since attitudes, knowledge, and application of skills that individuals learnt in other environments will be effectively incorporated in others for the benefit of an organization (Cheng, 1998). This according to the author increases learning and helps professionals develop their capabilities further. For transferability of skills to work, there has to be different professionals with different skills and capabilities. Research studies indicate that skill mix plays a significant role in creating an environment for development of capabilities (Dyess & Sherman 2009, p. 243).

Rallings (2009), outlines and explains some important and relevant skills for community nurses. He notes that community nursing involves taking a step out of the ordinary hospital environment to offer professional nursing care to individuals in different locations who need health care (Rallings, 2009). Their skills include collaboration, advocacy, and policy enforcement, among others. Unlike other nurses, community nurses are expected to have skills in surveillance, community organizing, social marketing and outreach. Community nurses play a crucial role in performing disease and other health event investigations. As a result, they are expected to have good investigative and research skills.

McCormack, Kim and Robert (2004) discuss how practitioners can be enabled and supported to initiate and implement development and change. The authors state that in contemporary health care, the practice and development of skill mix has been constantly emphasized despite it being misunderstood (McCormack, Kim & Robert, 2004). As argued by the authors, creating a developing practice for skills mix requires that the medical sector understand achieving a successful change is a complex process that calls for them to operate within an appropriate framework (McCormack, Kim and Robert, 2004). This should be the case in community nursing where the people involved need to understand the complexity of skill mix and its role in skills transferability.

McSherry and Jerry, outline the meaning of excellence in practice. According to the authors, health and social care standards, clinical governance and evidence-based practice were some of the illustrations of excellence that core contemporary issues used (McSherry and Jerry, 2008). They outline key topics involved with ensuring quality in the healthcare sector. One of them is national service frameworks which covers areas such as community nursing. Excellence in this area of practice can be achieved through different initiatives such as skill mix, which will allow transferability of skills and knowledge by having differently qualified personnel working together and learning from each other.

In his article, Trautman (n.d) explains how to support change with knowledge transfer skills. The first steps according to the author include identifying the areas that need change, identifying strategies that are already working and those that are failing, and identifying ways through which information can be moved efficiently. As explained by the author, skill mix supports knowledge transfer through on-boarding new employees, merging different teams together and cross-training professionals.

Skill mix supports transferability of skills and knowledge by allowing nurses with a specialty in different areas to share it with others. They share their skills and knowledge in a specialized way serve as the go-to-person and train many people (new or existing) on the topic they have specialized in (Trautman, n.d). The centrality of the people working together as a team helps them improve consistency and improve potential for every member of the group. Supporting knowledge transfer according to the author includes defining roles and clarifying the expectations of each of the roles performed.

Skill mix creates a set up where each person is able to say where they would be glad to help. Skill mix initiatives further recognize that it is not possible for one to succeed at their job if the rest of the team is not up to speed. Through skill mix, every member of the team is prepared for future leadership roles (McSherry and Jerry, 2008). Team meeting, schedules and other activities involved in team work are well taught to every member of the team. To improve the team’s success, every nurse would be willing to play their role in ensuring that collective results are good. Instead of working as competitors, nurses will be able to work towards a common goal and enjoy better results (McSherry and Jerry, 2008).

Bourgueil, Philippe, Julien and Engin (2008) explain that if the nursing sector wants to fully reap the benefits of skill mix, it must identify the type of job to be done, time required and the availability of relevant skills to tackle the job. One of the challenges identified by the authors is turf protection. These sentiments are echoed by the The National Pharmacy Association (2010) who further argue that to effectively and efficiently meet the health care needs of individuals outside the hospital walls, community health care gives must first discover what set of skills are needed, where and which people will do the job. This will be determined in line with the diverse services to be offered. Problem solving methodologies, soft skills for change agents, statistical tools for accomplishing different investigative and research assignments, among others, should be established too.

Fisher (n.d) explains skill mix in the context of community nursing. The author argues that implementing skill mix requires that all stakeholders adopt strategies that are practical. Additionally, all decisions they make must be knowledgeable and be based on evidence that works (Fisher, n.d). It is imperative to note that other than treating skills mix as a cost saving measure; it should be observed as a means of clinical effectiveness and should be led and evaluated by clinicians (Kuokkanen & Leino-Kilpi, 2000).

Fisher’s work illustrates that the right combination of skills will enhance community nursing outcomes by allowing skills, knowledge and ideas to be transferred and shared among each other. However, the author warns that inappropriate skills substitution will not bear much fruits. Instead, it can lead to more vacancy rates due to a decreased morale (Kuokkanen & Leino-Kilpi, 2000). The book discusses delegation and accountability, as well as their roles in ensuring that challenges facing skill mix initiatives are resolved appropriately.

Mashaba (1994) takes a closer look at transferable skills in nursing and points out that transferable skills in practice paradigm allows nurses in their nursing practice to identify which aspects they can relate to others and which are relevant to the duties the intend to take up or are necessary to their other roles(Mashaba, 1994). The book concludes that transferability of skills and knowledge is a critical element of learning. Depending with the settings, transferable skills can be specialized or general skills in the practice such as group work and data handling skills.

Skill mix is applicable in the entire medical profession, especially in nursing, as explained by Banham and Conelly (2002). These authors elaborate on whether skill mix is a substitution or diversification technique. According to the authors, skill mix can be implemented to achieve either of the two. However, using skill mix as a diversification technique serves more benefits than substitution. Diversifying the skills and responsibilities of community nurses allows them to do perform more responsibilities, while being able to deliver in their core responsibilities (Banham & Conelly 2002). One way through which this happens is skill and knowledge transferability. Instead of substituting a nurse and replace him/her with one who has the desired skills, a team of skilled nurses working together allows them to share and transfer skills to each other, and in the long run, the team is equipped to perform most of the tasks on the ground.

Buchan (2004) explains four major stages in the implementation of skill mix. In the context of community nursing, he points out that these stages are driven by several questions including what the sector needs to address by implementing skill mix, what the span of control is for the sector, what resources are available and approaches through which skill mix can be implemented. The skill mix cycle as explained by the author includes planning for change through available resources, using a ,span of control to identify opportunities and barriers for change, making a change to happen by identifying land implementing solutions and evaluating the need for change (Buchan, 2004).

These guidelines are further explained by Buchan and Calman (2005) who explain that among other considerations, there is need that staffing configuration and available skills be looked into first. Change is not possible if there is no clear direction of the starting and ending point. To successfully implement effective skill mix, there is need to evaluate its effects. There has to be a clearly set and defined baseline indicator. Factors to consider in this step include activities and roles performed indicators for measuring outcome, the needs of different client groups, quality of care provided and that expected, staff involved, and their availability and capabilities. After these factors have been put into consideration, the authors further explain that an assessment of skills to be transferred and shared should be done (Buchan and Calman, 2005). This step involves identifying the most urgent needs and assessing how applicable available solutions are.

When these steps and factors have been considered and undertaken, it is then easy to use skill mix as a way to transfer skills and knowledge within nurses. Identifying the current situation of a team allows them to identify what is lacking and which skills need to introduced. It is through such initiatives that nurses are able to learn and get skills from the rest of the team. The end results are a fully equipped team with capabilities to perform most of the duties, without having to recruit new nurses with specialized skills into the team.

Buchan and Dal Poz (2002) review the evidence in the of skill mix in the healthcare workforce by discussing the reasons why it is so important. Evidence collected from their research indicates that there is a lot of underutilized avenues for developing the community nursing profession. Mixing different skill mixes in various community programs will allow the sector to explore new roles and skills.

Benner (2001) offers appropriate mechanisms that can be used to help community nurses develop from novices to experts. Perhaps this is the biggest role of skill mix and skill transferability (Benner 2001). The author addresses excellence and power in clinical nursing practice. Incentives, recognition, rewards and strict discipline measures are key strategies towards ensuring that nurses deliver, work together, benefit from each others diverse skills, and stay disciplined. When such measures lack, the sector’s efforts to use skill mix as a skill transferability initiative may not be rewarding.

Leadership plays an important role in how skill mix initiatives are implemented, and the role they play in skill and knowledge transferability (Borbasi & Gaston 2002). To understand leadership and its role in nursing, Borbasi and Gaston (2002) explain the concept by categorizing them into different classes. They classify them into organizational management, creation and vision, communication and strategy. When a leader understands this, he/she is willing to stay in line with the management and follow the hospital’s policies and regulations. As leaders, managers should work on being more visionary and equip themselves with the required strategies. Such qualities will help them direct their teams and services to a better future in the industry. To be an effective leader, they also need to work on their problem-solving skills, which the authors point as a fundamental element of a leader and a mentor (Borbasi & Gaston 2002).

The need for professional ethics and mentorship is addressed by Constable and Russell (1986) who explain the effects of social support and the work environment among nurses. Through an empirical study on 310 nurses at an Army Medical Centre in Colorado, the article points out that burn out is a significant problem among nurses, and needs to be addressed urgently (Constable & Russell 1986). The results revealed that major determinants of burnout and skills deterioration include lack of motivation, physical discomfort and decreased performance, among others.

This is further supported by Canham and Joanne (2002) who addresses the challenges and opportunities in relation to mentorship in community nursing. They begin by pointing out that due to the expansion in primary care, there has been an increase in the number of community practice teachers (Canham and Joanne, 2002). Special areas of community practice include children’s community health, occupational health nursing, health visiting, and general practice. Skill mix can be used as a knowledge transfer initiative by having nurses specialized in these areas work together. The results will be community nurses with capabilities to work and serve in any of the specialities mentioned above, and many others such as community nursing mental health.

This is further developed by Cribb (2005) who sets healthcare ethics in social context by explaining the need for professional ethics, guidance and mentorship in the sector. Cribb (2005) points out that mentorship begins in nursing, and should not stop after people have grow their career to senior nurses. This is vital in ensuring that nursing students have the right perception about nursing even before they begin their careers. Just like students, senior nurses need support and mentorship from managers and other people above them.

Policy instruments that support skill mix can be understood more clearly by reviewing Buchan’s work (2004) and other authors that agree with him and support his arguments. According to the author, nurses change their roles indirectly by modifying the interface between service skill mix impacts directly or indirectly in initiatives focus on changing professional roles (Buchan, 2004). They do so directly through delegation, having new types of workers introduced in the profession, change of roles and skills, and introduction of new skills.

Buchan (2004) continues to explain that skill mix initiatives are motivated by various factors. Motivation includes both qualitative and quantitative considerations. Qualitative considerations include professional development, work concerns and quality, as well as quality improvement. Quantitative considerations include the need for cost-effectiveness, shortages and wrong distributions of a workforce.

One of the policy instruments supporting effective implementation of skill mix is overcoming institutional barriers. Others include regulating professional scopes of practice and modifying or introducing new professional roles. This can be done through regulatory arrangements and the development of different organizational (Cowen and Moorhead 2006). Like many other professions, nursing is slowly evolving to meet the current needs of their clients. As this happens, training and skill development is changing to meet the expectation of different stakeholders in the industry.

Another policy supporting skill mix initiatives is using collective financing and altered financial incentives to support new or enhanced professional roles (Dierick-van Deale et al., 2010). Cost cutting measures have a significant influence on initiatives implemented in the healthcare industry. Financial incentives put in place have to be able to give considerable returns to the stakeholders. The third policy supporting skill mix is ensuring that the roles of professionals are expanded and that new completed and capacity educational foundations are established (Eastaugh, 2004).

However, WHO caution that the drive for any initiative as the nursing industry tries to implement skill mix must be must be sensitive to the professionals and to the system (World Health Organization, 2006). As further supported by Harris (2005), he explains that new professional roles in affected professional organizations should be supported by the government across the initiatives. One size approaches aimed at meeting all the objectives do not work. Specific initiatives must be set to meet specific goals and objectives.

Bourgeault and Mulvale (2006) explains in details how skills and knowledge transferability is a solution to skill development. Their work is further supported by Buchan who asks the question of whether skill mix is the solution and if so what happens to be the answer. Bourgeault and Mulvale (2006) give a background of these problems by explaining that the nursing profession is marred with shortages and imbalances in culture, gender and other social factors. The number of nurses needed each year to cope with increasing demands for healthcare are far much more than the number of nurses graduating from colleges every year. The US Bureau of Labor statistics support the authors’ arguments by stating that in the United States, the healthcare sector is constantly growing and there had been a creation of more than 37,000 new jobs created in the month of March alone (Bourgeault & Mulvale 2006). However, only half of these nurses will be a available to fill up the positions.

Buchan (2004) confidently states that skill mix can serve as an initiative to support skills transfer and as a solution to the current situation. Skill mix allows the creation on new responsibilities and roles, by allowing people trained in different professions to interact. Creating new roles and responsibilities also allows nurses to easily delegate their duties amongst themselves, since everyone is equipped with the necessary skills through transferability. As result, there is more delivery of services with the available number of nurses available.

One of the major skill mix initiatives is training and capacity building. Training and capacity development through working together, mixing skills and transferring them to each other allows those under training to undertake more responsibilities and tasks than they did before. Through training, the nursing industry will be able to develop the skills of those in the sector but are not necessarily trained in specific areas of specializations (Bourgeault & Mulvale 2006). To be able to serve more patients today, these will allow nurses to do more than they were initially trained for. For example, nurses who have been trained to take care of patients, do ward rounds and other tasks in a hospital may not have much experience on how to perform complex community nursing duties. By working together with more experienced nurses in the field, the need to go back to school and be trained is reduced (Bourgeault & Mulvale 2006). Furthermore, through practice and referring to what the rest of the team is doing, practical skills development is made possible.

However, Bourgeault and Mulvale, (2006), warn that it is important to realize that forced skill mix will not deliver much. The industry must implement its strategies in consultation with nurses and all the people affected. A sector which has an open communication culture allows employees air their concerns and complains, some of which may be affecting their service delivery. It also allows managers and the executive to relate and connect better with every part of the organization including employees at the lowest level. Healthy communication between people on all levels is a good way to source information and allow the executives make more informed decision, considering every person’s needs. A sector which adopts a culture of punishment for poor performance may be able to improve its productivity but will not enjoy the loyalty of its employees since they work from fear.

Buchan (2004) explains that training and sharing of skills are aimed at preparing individuals to keep their skills updated and ready to undertake higher levels of work when chances arise. It also provides a possibility of performance change. Skill mix allows skill sharing through skill transferability and will help the community nursing sector retain their pool of human resource and stay up-to-date with current and relevant skills in the market. It also makes the nurses feel cared for and they are then motivated to give better quality to their clients.

Bourgeault and Mulvale (2006) explain in details the factors influencing the ability to scale up skill mix initiatives. One of them is contextual framework. They cite Dyro’s work in their literature and explain that there are three skills mix initiatives that enhance or impinge its scaling up (Dyro, 2004). Macro factors cover the influence of regulations and policies that cover practice such as education systems in different regions, professionalism as understood in different regions, and statutory recognition of nursing in that particular region. Economic domains are also part of the macro factors.

Factors at the meso level include those in the local organizations’ level such as institutional arrangements. They include educational systems, organization’s settings and community’s expectations. As cited in the author’s work, Culyer and Newhouse (2000) explain that the quality of skill mix initiatives are affected by contextual micro-level factors at the level of everyday practice. Those factors include previous experience they have had with skill mix initiatives and interpersonal relations between the various health professionals.

In view of these considerations, through the development of regulatory changes and organizational arrangements, policy instruments for skill mix will need to allow the introduction of new professional roles. They will have to support the new roles through available and new policies such as collective financing to ensure the whole public is involved. Any policy instrument for a skill mix will also need to ensure that competence and capacity for the new roles are located at the right place.

As summarized by the two authors, contextual factors affecting skill mix initiatives can be broken down into macro, meso and micro as below;

Economic factors

Insurance coverage

Legal and regulatory factors
Registration requirements

Scopes of practice

Education and training

Provide accountability

The way providers are paid in different nursing disciplines
The level of funding and its stability does affect skill mix initiatives
This is very significant especially for any new roles of providersDifferent levels of professions require different registration levels
Substitution of professionals is allowed through overlapping scopes
New skills require an improvement on existing levels of education
Comfort in delegation and compatibility of insurance
Provider supplyStakeholder support

Local health system
Population health needs

Population health needs are addressed when suppliers are available
For or against support is important for lobbying change
Skill mix must fit gaps in service delivery in specific
Consideration on cultural, demographics of the local communities being served

Work relationships

Practice styles

Implementing formal and informal channels of communication between involved professionals
Preparation for insecurities and any uncertainties that may arise about skill mix
There will be evolving relationships between professions in skill mix initiatives and they must be beneficial
Adjustments must be made to address differing practices, expectations and differences in professionals involved in skill mix

Skill mix may involve creation of completely new skills and responsibilities, or transfer of existing skills from one nurse to the other. It could also involve re-structuring different areas of community nursing to meet different needs other than the existing ones. In many cases, regulatory changes have to be effected to allow a full implementation of skill mix. Accommodation of overlapping costs of practice during the regulation of professional scopes of practice and can either enable or hinder enhancement or substitution opportunities since they are particularly very critical (Denny and Earle, 2005).

Like every other initiative, skill mix as a professional development technique faces several challenges and hindrances. In countries where skill mix has been pursued to integrate and in-collaborate effective services such as Germany, their biggest challenge still remains the fragmentation of the healthcare system (WHO, 2007). Countries such as Russia, which have pursued skill mix initiatives with high levels of commitment, are still not able to implement it as it should, due to the same challenge and many others. As Coombs (2004) explains that occupational groups, poor coordination across the various sectors and lack of uniform regulation of provider organizations are other barriers which are embedded in the stakeholder arrangements and regulatory framework.

Further challenges arise from the fact that the community nursing sector is polarized by many associations and funds, a factor that makes it hard for the industry to introduce any new professional groups into the existing teams. Any interventions from external stakeholders are always met with resistance and long processes of consultations. Organization of the many healthcares and their regulations has been observed to be highly physician-centered (Freeman, 2000). Even as states take up more interventionist roles, incentives and policies in the sector continue to be heavily focused on the professional aspect community nursing.

In Spain, as it is with the decentralized system of healthcare provision, many institutions with different interests have been involved in decision-making processes about human resources for health (Hall and Buch, 2009). Such a situation makes it too hard for involved stakeholders to come into consensus on the necessary regulations, working conditions, training requirements and other important structures required in skill mix. Community nursing managers are faced with limited flexibility and are not able to negotiate their way forward as they try to implement skill mix in a way that benefits everyone. Even though many governments remain crucial in the structuring regulations, they still have a limited capacity to enforce the commitment of nurses to the objectives of skill mix.

Hall and Buch (2009) further explain changing incentive structures as another significant factor affecting the ability to scale up skill mix initiatives in community nursing. “Appropriately implementing new or enhanced professional roles for existing professionals have been highlighted as critical factors in the success and sustainability of skill mix initiatives” (Bourgeault and Mulvale, 2006, p. 5). This is evident in countries such as the United States, Canada and the United Kingdom. The benefits of skill mix are negated when the current professional group skills are comparable to that of substitute professionals (Hutchinson, Marks and Pittilo, 2001).

There are many other factors that influence how skill mix initiatives and their role in skill transferability are implemented. For example, the government of Russia support potential skill mix initiatives since most human resource issues is defined by the federal law of labor (Jones et al., 2005). Weak professional development mechanisms still pose as one of the major challenges for regions trying to implement skill mix in their nursing sector. The decision on whether to develop and upgrade nurses’ skills in a school setting or have this is done during practice through skill mix, is many times based on available structures.

Educational competence and capacity are critical determinants of what role skill mix plays as a professional development initiative in community nursing. If a team is made of inadequately trained community nurses, then they may not be able to influence each other positively as far as skills and knowledge are concerned. To understand why this is a significant factor, Mason and other authors point out a few case studies where this has been experienced. “As observed in the case of the United Kingdom, the capacity to train for new professional roles and educational competence for enhanced professional roles is vital (Mason, Coleman, O’Keefe, Ratcliffe and Nicholl, 2006). This calls for proper and effective educational delivery structures in community nursing training institutions. In countries such as Spain where community nursing programs only involve short training programs, educational capacity and competence has been a significant concern. It is for this reason that the country has been for a long time debating on whether teaching of community nurses should be upgraded and the scope of training be expanded.

Successful transfer of skills in a team is achievable when things are done in a systematic order. There has to be a detailed establishment of skills available, and those lacking in each member of the team. To understand this procedure, the skill mix cycle is explained in details by Buchan using his research and other authors’ works as quoted in his article. Among the works he uses is that of Maynard and Scott who explain that the first step in skill mix implementation is evaluating the problem (Maynard and Scott, 2003). Change is not possible if there is no clear direction of the starting and ending point. To successfully implement skill mix as a skill transferability initiative, there is need to evaluate its effects. There has to be a clearly set and defined baseline indicator. Factors to consider in this step include activities and roles performed, indicators for measuring outcome, the needs of different client groups, quality of care provided and that expected, and staff involved, there availability and capabilities. After these factors have been put into consideration, assessment of the problems that will be solved by skills mix changes should be done before implementation (McCormack and McCance, 2010).

The second is making change happen through identifying and implementing solutions. The third step involves identifying the opportunities and barriers for change. This is through establishing the span for control. The last step is planning for change. This step is where an honest assessment of available resources should be done. It is also the step where required resources are identified and possible returns evaluated.

Why community nurses need skill development

Community nurses play a critical role in ensuring that primary nursing care is available to people with different medical needs. Over the years, the roles of community nurses have been aimed at meeting a continuum of health needs. Such needs include public health promotion, community development and management of specific diseases (Richardson, et al., 1998, p.190). Care programs for a patient must consider all the factors that affect his/her needs and health status. Making sure that these factors are right is a role that has been left to nurses in the hospital (Loon, 2007). Outside the hospital, nurses still help ensure that they carry out their roles in the community by ensuring that health needs of people are met. It is imperative to note that the roles of community nursing is shifting from the hospital environment to transitioning clients as they seek to provide them with nursing care to prevent and manage diseases (Loon, 2007, p.4). Therefore, as Sackri et al. (2007, p. 194) puts it, it is importance to prepare new nurses in community context to understand the nature of the field through competencies development. This will ensure that they carry out their tasks effectively and efficiently.

Changing social demographic

In the world today, due to efficient health care systems, many countries are experiencing a vastly improved life expectancy (Spreeuwenberg &Vrijhoef, 2010, p. 29). The demand for health and community services is going up as more countries put in measures to reduce mortality rates due to different reasons. Research studies have indicated that even though life expectancy has improved in this nations, profound disability has increased among the aged from about 5% to 50% between the ages of 70-90 years respectively (Loon, 2007, p. 12). This combined with the fact that the baby-boomers generations are approaching these numbers of years, the need for community nursing is only expected to escalate (Buchan 2004). There is need that health care organizations to do planning and set appropriate strategies to increase healthcare workforce to meet the health needs of this generation and those to come.

This issue is further complicated by the fact that most aging persons today are no longer taken care of by their families and relatives. This is due to a number of factors that include change of attitude towards the aged, neglect of the aged, reducing number of children among couples today, escalating numbers of divorce and geographical distances among others (Porter-O’Grady, 2003, p. 107). These factors set a stage for a growth in demand for community nurses and their services.

To effectively address the increased demand for community nursing, it is inevitable that many governments and region will need to invest heavily in skill development as far as community nursing is concerned especially on new graduated nurses (Wangenston et al. 2008). Stakeholders will need to redesign care and service options to allow community nurses perform more duties and serve more people. Even with the best intentions, nothing much will be achievable if skill development in community nursing is not properly addressed (Loon, 2007, p. 12).

Changing acuity and complexity of clients

Recent research studies have indicated that increased complexity of care demands has been brought about by changes in the environmental factors, lifestyles and demographics. (Loon, 2007, p. 12). The number of aging populations is on the rise. The number of disabilities is still significantly high in most regions. There is also an increase in the number of people suffering conditions that restrict them from core activities (Loon, 2007, p. 12). Such conditions include stroke, musculoskeletal, respiratory complications, just to mention a few. As such, individuals will lack the ability to self care due to the impacts of complex comoboid conditions (Buchan, 2004, p. 12).

At a time when the world does not have lasting solutions to the above named trends, the need to prepare and equip community nurses with appropriate skills is overwhelming. The WHO has embarked on skill development programs for nurses that it intends to achieve through many initiatives such as training, coaching, and skill transferability possible through skill mix (Kernick and Scott, 2002). Skill development and any other initiatives considered must be able to meet the needs of the nurses, and do so in a favorable cost (Loon, 2007, p. 12).

Changing value systems

The influence of diverse value systems in community nursing affect the perspective individuals have on the role of professionals in situations of sickness or wellness, of others in community nursing, nurse and client interaction and on the illness, health, wellness, community and disease (Loon, 2007, p. 20). In the past years, self-medication was an acceptable practice and posed no dangers to the people of a community. Today, health complications are more diverse and one solution may lead to other complications (Bourgueil, Philippe, Julien &Engin, 2008). Drinking alcohol was considered as social pastime activity that brought no harm to the people. Today, modern brews pose major health risks to the consumers.

As these changes occur, community nurses need cultural competence to be able to influence medical decisions of the people they are serving (Blank and Burau, 2007). In order to serve the people effectively and avoid resistance, they need to align their value systems with those of the people. This is a bigger need today in increasingly multicultural communities. It is important for community nurses to be able to address the differing practices in communities and address any obstacles that stand in the way of giving professional care. Nurses can do these through skill development and working with other nurses who understand the people they are serving more. Therefore, skill transferability is not just restricted to professional challenges, but also other skills such as dealing with people (Borbasi and Gaston, 2002).

Changing scope of practice

Along with other regions in the world, North Batinah, the place chosen for this study, is experiencing a shortage of nurses. The community nursing sector is affected by the shortages and may not have enough professionals to attend to all the duties (Cowen & Moorhead, 2006, p. 40). Expanding community nurses’ professional roles will improve decision-making and expand the scope of community nursing (Buchan & Calman, 2005, p. 20). Therefore, skill development is critical to the region’s capacity to meet its community nursing demands.

The scope of nursing can be expended through various ways. It can be done by adjusting curriculum in schools, increased years of schooling, training, coaching, just to mention a few (Gaist, 2009, p. 42). It is also achievable through skill transferability where nurses with different skills work with each other, influence and learn from one another (Buchan & Calman, 2005, p. 20).


To sum up, as already mentioned, health care professionals and managers of the National Health Service have been divided over the pursuit of skill mix (Benner, 2001, p. 100). Opponents argue that if it was to be adopted fully, the threat of losing quality in the sector would be more real. Such a measure would also lead to the erosion of value for quality.

Proponents argue that skill mix will allow the healthcare sector to develop skills through skill transferability and other procedures. The debate over the issue of skill mix continues to heighten and more issues keep arising. For example medical professionals argue that decisions on whether to implement such initiatives should be entirely left to them since the government does not understand the complexities of the profession.

In the context of community nursing, skill mix can be used as a skill transferability initiative. According to Borbasi and Gaston (2002, p. 32),skill mix has numerous benefits that include creation of innovation roles, staff substitution between different groups and enhancement of skills among groups. The sector will many times take the option of hiring and working with unqualified personnel that spend money on conducting further training on nurses. Skill mix works well in ensuring that the health needs of the local population is mat effectively and efficiently. This is achieved through its ability to align health services (Wrede, 2008).

It is important to realize that skill mix works by ensuring that each community nurse has a unique cluster of skills, a very significant factor in the completion and success of various team works. Skill mix can be used as encouragement to have community nurses expand the scope of their skills and knowledge, and develop different styles that suit the current medical needs (Ministry of Social Affairs and Health, 2002). When skills are properly nurtured and developed, it is easier for them to be transferred to other team players in the course of working together. This research paper is aimed at researching on these arguments and giving a conclusion and recommendations based on the results.


The collection of data for this research study will be done using focus group interviews. The main goal of the research study will be to gain insight and understanding on the impact of nursing skill mix on professional development. The primary research method for this study will be structured focus group interviews which will be conducted when gathering data using the quantitative method. Focus group interviews will be important for this research study since participants, caught in the spirit of discussion, will provide detailed information and answers to discussants interview questions on skill mix.

The focus interview will target 15 expert nurses. The focus group will be divided into two groups of between 6-8 participants. This will ensure that in the discussions, every individual gets an opportunity to participate (Kruger & Casey, 2000). The focused group discussions will be held in a neutral location such as a hospital, conference hall or a hotel meeting room away from other workers. This will encourage candor among participants in the focus group.

The interview questions to guide the focused group will be divided into three sections having a total of twenty one questions. For a four-hour focus group, the first section questions will make general inquiries such as “what were the reasons that motivated you to join nursing profession?”And “What are your reasons for getting involved in community nursing?” Giving participants ample time to pursue issues will ensure that facilitators gain important information (Kruger & Casey, 2000). The second section of the interview questions will be designed to prompt discussions aimed at understanding why the respondents have chosen to stay in the profession. There will be different reasons to choose from varying from financial reasons, career development and relationships at work. The third and most significant section of the interview will seek to gather information on the role of skill mix in professional development in the community nursing sector. This section will cover the participants’ understanding of the concept of skill mix, their appreciation for it, and their views on its relevance in the sector (See appendix I for interview questions). The initial findings of the data will be focused on three main questions;

  1. Reasons for joining the nursing profession and why they chose to be involved in community nursing
  2. Reasoning for staying in the nursing profession
  3. Role of skill mix in professional development from the participants’ view

Data analysis and discussions will be written from the findings in different academic resources, the survey and the interview. It will review and classify findings from different statistics and the situation in the community nursing sector as far as skill mix and professional development are concerned. It will also present statistics and information collected from the outlined sources to get a professional understanding of the topic (Kruger & Casey, 2000). The findings will be used to structure an argument and different discussions. The healthcare’s position and capability to manage skill development will also be reviewed, discussed and evidence presented. The results will be interpreted and a more detailed examination given. (see appendix III for interview questions)


A total of 15 participants will be chosen based on their level of experience and understanding of professional development in community nursing. To collect comprehensive qualitative and quantitative data, the participants for this study will be sampled into two groups of between 6-8 people. Even though this study will be open to all employees in the community nursing sector in North Batinah region in Oman, those who are not expert nurses will be excluded from the study. The interview will be aimed at understanding how the culture of skill mix appreciated in the sector, by studying how are able to provide quality through skill development. The interviews will further discuss the need for professional development and training among community nurses, and the role of skill mix in skill transferability.

The interviewees will be expected to have a good understanding of how the culture of skill mix is applied and appreciated in nursing, especially as far as community nursing is concerned (Kruger & Casey, 2000). They will be further expected to understand healthcare trends in different regions. Since the interviews will be used to discuss the role of respecting professionals in the healthcare sector and how skill mechanism can be used as a solution to different challenges facing the sector, a long term experience in the sector will be required.

To ensure gender balance in the study, 60% of the participants will be female, while the remaining percentage will be male. The reason for this is that involving all employees in the nursing sector regardless of their sex, category or specific location in the area will ensure that the survey collects comprehensive information representing all employees in the community nursing sector (Kruger & Casey, 2000). There will be an age limit of 28 years and above to ensure information is only collected from experienced participants. The questionnaires will be accessible to the participants for a period of three months to ensure participants fill them at their own time without pressure.


Recruitment will be done by using social network and online forums to reach out to targeted participants. For the interviews, specific people will be contacted on the phone by fetching their numbers from directories. Sampling method will be used. Information gathered from 8 participants will be used for qualitative analysis while that from the remaining 7 participants will be used for quantitative analysis. All participants will be presented with adequate explanations and guidelines for the study. All participants will also be required to fill and sign a consent form agreeing to voluntary participation. The snowball technique will also be used to reach the targeted number of participants required for the study. In this technique, people familiar with the study will be used to reach out to more people who will then be directed to the research’s weblink.

Data collection

The research methodology applied in this research project would be designed to achieve the set objectives of the paper. Primary data collection will be done through focused group interviews. Although secondary data will not be the main data collection method, other relevant skill mix information will be collected from past research projects, government and non-governmental statistics and other relevant sources.

The interviews will be used to further establish how this has been taken up in different regions such as the United States, the Asian region and the European countries. They will further be used to seek the experts opinion on how through labor regulations, the sector is being forced to establish consultation channels between all the relevant stakeholders before decisions are made. The interviews will further be used to discuss the role of respecting professionals in the community nursing sector and how skill mechanism can be used as a solution to different challenges facing the sector. Creating favorable work conditions is another important issue that will be discussed in the interviews, as well as how far the nursing industry has come in achieving this.

Another significant topic of discussion with the interviewees will be community nurses’ satisfaction and its role in quality ensuring quality in the sector. This topic will cover promotions and career development and how they are being addressed in the nursing profession. Process improvement will be analyzed to understand how by making effort to make a working system better, the sector can make it easier for medical professionals to work. Other important measures to be discussed in the interview will include the role of a good corporate culture, job enrichment and effective skill development.

Case design

The case design will be comprehensive and complete enough, to allow stakeholders understand and utilize the information in decision-making easily, whether they were part of the research team or not. These stakeholders include nurses, other medical professionals, government officials, and other stakeholders. Reviewing a case design should be critical to ensure its validity and applicability (Farr, 2011). This will be ensured in this research project. Cross-comparing the case design and its outcome, with similar research projects conducted in the past, will help this research to highlight commonalities and identify areas where the results need to be strengthened. Data analysis tools and software will be beneficial when sorting out data and identifying patterns. Laurel (2003, p. 43) argues that gaining greater insight into trends require proper data analysis techniques.

Justification of the methodology

Appreciative inquiry

Appreciative inquiry indicates that individuals’ perceptions and perspectives of phenomena are a source of their problems (Laurel, 2003). The approach will be applicable when identifying what has worked well in the past and applying it in the current situation. This proved the most applicable methods when researching on the healthcare sector’s development and strategic planning. The method will prove particularly relevant when gathering information that will help the sector develop their development plan.

Case study design

According to McBurney and Theresa (2010, p. 230), in order to implement any skill mix initiatives, the sector will need to confirm the effectiveness of its programs and processes. This entails evaluating their strengths, weaknesses and threats. A case design in this research will include arranging a wide range of information from different sources and similar projects in the past by the medical sector or other stakeholders. Comparing the results and patterns of past project will then help this research make relevant conclusions and recommendations. Evaluation will include both straightforward comparison and in-depth analysis.


Interviews are a brilliant way to pursue in-depth information about a project. They are particularly helpful when a case needs follow-up, and when answers are required from a particular person (Farr, 2011). Preparing for interviews will involve choosing settings with the least level of distraction, explaining the purpose of the interview to the interviewees, explaining the purpose of the interview to them, and recording it for reference purposes (Laurel, 2003, p. 13). This method of research will be beneficial when trying to understand the concept of community nursing, how skill mix can make it better, and any other information that does not involve a large target group.

Focus interviews

Focus interviews will be the most convenient and easy way to collect data from a large population. They are easy to design, and since they do not require a lot of time, it is easy to have respondents to cooperate. Since the target group in this research project will be 15 people, focused group interview will be considered the most efficient way of gathering information and opinions from them.

Data analysis

Jones (2000, p. 562) indicates that data analysis comprises of diverse techniques depending with the type of data, and expected outcomes. When conducting a skill mix study, data mining is an indispensable technique since it involves discovering knowledge, as opposed to describing it.

Furthermore, Jones (2000, p. 562) states that in such a project, it is expected that at least 90% of the interview questions will be correctly answered correctly. Interviews will be scheduled early to guarantee enough time for preparation by participants. Secondary data will be extremely valuable and will be collected to augment the research. Before any data is collected, permission will be sought from different authorities such as the relevant ministries and health institutions where the participants work. An initial visit to these institutions will be crucial for introductory purpose, familiarization as well as seeking consent for the research project.

Data analysis tools and software will be beneficial when sorting out data and identifying patterns. As Punch (2006, p. 112) argues, available data analysis tools today include business intelligence platforms, the online analytical processing, excel power, among many others. Answers to close-ended questions will be analyzed in percentages while others will be individually analyzed and discussed.


Some interviews will be conducted on the phone. Any information required from government officials will be accessed online, after consent from concerned authorities. Sample investigative questions in this survey will include having participants explain what they understand by skill mix, giving examples of experiences they have had themselves in skill related initiatives. For the rest of the interviews, there will be need to arrange for venues where they will be conducted. Financial resources required for the project are outlined in the budget available at the appendices.

Expected outcome

For the proposed study, it is expected that it will be possible to identify the role of skill mix in professional development. The survey will be focused on community nursing and how skill mix allows the development of skills. It will focus on the role of nursing skill mix on transferability of skills and knowledge among registered nurses working in the community nursing context. It will study the allocation of different skills to nurses to work in one primary healthcare organization.

Interviews conducted on health experts, government officials and other stakeholders will help fully understand the background of the problem, and give a professional view. It is expected that from the information gathered, it will be possible to identify what stakeholders have done so far, what is working and what has failed. Such information will be vital for any country with ambitions of using community nursing to develop a healthy nation.

This research is significant to every citizen of the country. Every country recognizes that the quality of healthcare determines its future. By ensuring proper healthcare decisions are made, a country’s investments and developments in the sector are bound to produce results. The research is also significant to the community nursing sector, policy makers and involved stakeholders. It is significant to the direction that training and skill development takes. It is further expected that the results will help shape the way community nurses and their role in the healthcare sector is viewed.

Skill mix as a substitution or diversification technique will be researched on and discussed. From the literature review, using skill mix as a diversification technique serves more benefits than substitution. Diversifying the skills and responsibilities of nurses allows them to do perform more responsibilities, while being able to deliver in their core responsibilities. This argument will be further researched, evidence gathered and evidence presented on which among the two best applies in skill transferability.

In the process, the research will also establish practical guidelines for community nurses to maximize skill transferability through skill mix. There will be practical guidelines for stakeholders in community nursing considering skill mix as an option to ensuring professional development. Necessary resources and steps will also be established through a comprehensive literature review on the subject. It is expected that steps and guidelines gathered on the same will be relevant, comprehensive and viable enough for easy implementation.

The research will further help understand the value of quality in skills in the context of community nursing. Quality in the healthcare sector is a term that has different interpretations depending with the approach that a person takes. It is defined as the extent to which a product or service satisfy a person or a group (Bannerman, 2002). Quality in healthcare is the process of meeting the expectations of patients and health service staff. The American medical Association views quality in health care in terms of the degree to which the probability of optimum patient’s outcome is influenced by the care services given to them. In health care quality is judged based on various domains. These domains include: effectiveness, capacity, safety, patient-centeredness, equity access and timeliness (Kim & Coyle, 2009).

Through the research, it will be possible to give suggestions and recommendations on the best quality improvement models. There are various quality improvement models that have been developed to ensure that services and products availed to clients are up to standard and that they meet the expected quality level. In long-term healthcare, extra attention needs to be to ensure that implemented measures are efficient enough and relevant for a long period of time. Applicable quality improvement models in community nursing include: Quality Assurance, Total Quality Management, Performance Improvement, the ISO standards and Six Sigma.

The research will be conducted with an understanding that community nursing is entrusted with a huge responsibility of improving the quality of life of a population. For regions where community nurses play a more significant role than just nursing, quality is both paramount and critical. As more regions compete to have the best healthcare in the world, several challenges and barriers are evident. Policy implementation has been a major obstacle for stakeholders who seek to invest in ensuring quality. The healthcare industry is strongly guarded by long policies and procedures of implementing even the smallest initiatives. As a result, small projects and initiatives might take too long and end up being irrelevant by the time they are incomplete.

Available quality improvement techniques include quality assurance which is involved with monitoring and evaluation procedures and techniques in a project to ensure that desired quality standards are met. In community healthcare, it is applicable to ensure that services provided are up to the recommended standard. Important techniques in quality assurance include putting in place checking and monitoring measures. The process involves assessment of quality to identify outlaying results so as to check if they indicate any inappropriate care.

Performance improvement is a significant technique easily applicable in skill mix to improve performance. Performance improvement is a concept that works towards continuous improvement and consistence in quality (Dunn, 2009). It is more focused on instilling quality in a particular product rather than trying to single out the errors present (Lockwood, 2005). It values the empowerment of individuals through trusting their abilities to improve quality, organizational learning, awareness and being sensitive to the patients needs. This model encourages continuous improvement, identification and prevention of defects (Buetow and Roland, 1999).

The research is further expected to help understand how community nurses can be empowered to perform more roles through skill mix. When well equipped and trained, community nurses perform diagnosis roles, they prescribe drugs, deliver children, do immunizations, follow-up on patients, and much more. By implementing skill mix initiatives, regions that have not been able to utilize their capabilities will be able to do so. For those nurses whose skills are more specialized, skill mix will allow them to perfect their skills even further by having every one perform what they are good at. For those whose responsibilities require them to perform different roles, skill mix will allow nurses to learn from each other, transfer skills to each other and increase their capabilities.

The research is also expected to gather views and suggestions on the role of technology in successful implementation of skill mix. Technology is important for effective management of key processes as the healthcare tries to implement and benefit from skill-mix (Winser and Keah, 2008, p. 100). It allows the stakeholders together with the work force to match the resources available with technology, through different approaches. The management is able to run operations more easily changing techniques and processes to better and modern ones. Through such benefits, community nursing can be taken to a level where it serves more purpose in different regions.

Skill mix management features personnel administration, organizational management, industrial management and manpower management. People in an organization are a key determinant of how successful it is going to be and how long it will last. It is expected that these views will be discussed in the interviews. As the labor markets get more and more competitive and the need for talent becomes more obvious for optimum performance, human resource managers are facing major challenges as they try to get the best in the market, retain them and ensure they have consistent performance. The nursing industry has especially been hit by a shortage and retention problems. This has especially affected the community nursing initiatives since they are mostly run by governments and more nurses prefer to work for private sectors. These issues will be discussed from available literature.

From the study, it will be possible to establish and discuss internal and external practices that influence community nursing in the healthcare sector. Internal factors to be discussed in the study include labor policies, training and support policy, shareholders and the labor market. External factors include government policies, legal factors, patients’ needs and technology as identified by Kotter and Heskett (1992). Since the healthcare industry is a significant part of every country, a global presence means that the behavior of different economies has enormous effects on its operations. The role of economical changes and trend, and how community nursing is run will be discussed.

Beck (2010, p. 34) argues that the nursing sector today is constantly changing and demands strategic planning and organization. Technological innovations such as Human Resource Management Systems have made it easy for sector to handle information related to skills, knowledge, training and development. It is expected that through the interviews and study of different literature, it will be possible to confirm these arguments.

The issue of competition between government and non-government medical services will be discussed and how this influences community nursing. Gaining competitive advantage as an employer has become a major challenge for the nursing industry. As the labor markets get larger and more competitive, strategic human resource management is a key recipe when formulating effective strategies in the industry. Stakeholder in the sector must be able to establish what works in their human resource management efforts and what doesn’t, to eliminate those strategies that waste time and cost the industry.

Ensuring open communication channels between employers and employees is the first step towards identifying problems and implementing solutions. In order for the nursing industry to realize the benefits various skill mix programs, incentives, recognition, rewards, and strict discipline measures are key strategies towards ensuring that nurses deliver, keep in line with a their organization’s timeliness, and stay disciplined. When such measures lack, the industry’s efforts to have the best talent in their workforce may not be rewarding. These issues will be discussed and analyzed, and recommendations made over how the government can be a better employer to community nurses. This is in recognition that skill mix initiatives in community nursing will not offer many benefits if there are not enough nurses to be involved in it.

Project time schedules

This research dissertation will be completed in a duration of 3 months

Project time schedules
The budget is presented at the appendices.

Ethical considerations

There were a number of ethical issues that arose during the formulation of this research proposal. These issues are further expected to arise during the collection of data for the project. One of the most fundamental principles to be followed in a research project is voluntarism participation (Houser, 2008, p.114 ). A participant must give consent before their identity is revealed if there is a need to do so, although for such a project, anonymity would be applied (Mathers, Amanda and Trent,1998).

During a research project, ethics also demand that the process must not subject the respondents to any danger or harm, a factor that will be taken very seriously. A researcher is supposed to apply the principle of anonymity to protect them from consequences of revealing the information they do (McBurney and Theresa, 2010). It is also the respondent’s right to be treated with respect and dignity during the study. These ethical issues are expected to be adhered to when this research project is being conducting.


Limitations faced and further expected in the research exercise is language barriers since the health care industry employee a large number of foreigners. This makes it a bit difficult to collect views for the study. Lack of cooperation from some respondents is also a significant challenge and there are always fears that they may not give accurate answers or take too long to respond. Conducting a research project is an expensive activity and finances pose as a challenge (Houser, 2008). These challenges will be addressed by conducting any investigations in English which is a common language, and using translators for participants that do not understand English. There will also be comprehensive explanations about the scope of the research to respondents to ensure they understand the objectives of the study. Explanations and elaborations are aimed at minimizing resistance. I will ensure a proper costing and allocation of funds is done before the task commences to take care of any financial challenges that may arise.

Skill mix as a subject raises very many controversies (Bluestone, 2006). Many medical professionals disagree on key issues related to the topic. While many feel that its initiatives could help solve several challenges in the medical profession, they disagree on how policies should be formulated and who should govern the changes that arise. Medical professionals feel that key decisions and their implementations should be left to them (Borbasi and Gaston, 2002). Government officials on the other hand feel that its their responsibility to foresee any decisions that affect those in need of medical care. Such controversies and debates may pose as a challenge during the research. Too much contradicting information and opinions may make it hard for the paper to come up with a well supported conclusion.


This survey is expected to strictly focus on the role of skill mix on transmission of knowledge and skills among registered nurses working in community context. Issues expected to arise in the survey include how different regions have implemented skill mix initiatives, and how well they have served as skill transferability techniques. It is is also expected that the research will help discuss and understand how well the concept has been received by community nurses. Challenges and opportunities will be discussed based on the data and information gathered from different resources, interviews and the survey.

Similar research projects conducted in the past include that carried out by The Queensland Government in 2009. The research was on community health nursing workforce development. It was based in Townsville Health Service District and focused on the current skill mix profiles in the region. The study defined skill mix as “the balance between trained and untrained, qualified and unqualified and supervisory and operative staff within a service area as well as between groups” (Queensland Government, 2010, p. 10). To gauge the skill mix profile, the report first established the number of new positions added in the region within the last twelve months, as well as number of nurses available for each of the grades. It concluded that skill mix would be a viable option to assist nurses through professional changes in the community nursing sector, and enable skill enhancement.

Another study was conducted by Carr, who focused on perceptions and practice in community nursing. The study, which uses needs assessment factors to drive decisions, suggested that complexity of skill mix is increased by recognizing the community context of practice (Carr, 2005, p. 74). The research also pointed out that skill mix and its role in skill transferability is an under-researched area. It concludes that skill mix can be used to address professional development through capturing skills from members of a team and making them available to other nurses.

Further areas of research on the topic in future should include the role of incentives in ensuring that community nurses appreciate skill mix initiatives and benefit from them. Such incentives include compensation for performance, effective human resource management and awareness on the initiatives (Fombrun, Noel and Mary, 1999, p. 67). This applies even in the healthcare sector. The task of managing employees in the healthcare industry should not be as daunting as it may sound, as long as the sector fully equips itself with the strategies, skills and knowledge to bring out the best of its employees. Despite the fact that proponents of human resource strategies have outlined their benefits to organizations for a long time now, they are not as widespread as may be expected. The results have been poor management skills and increased costs of hiring and training new employees every too often.

As explained by Taylor (2002, p. 44), effective skills management involves applying these strategies to employees’ management. This is further explained by Stewart (1995) who points out that incorporating appropriate strategies and plans in health care is imperative in mainstreaming skill management (Stewart, 1995, p. 66). It is also supposed to help organizations think strategically as far as human resources are concerned. According to Bratton and Gold (2003, p. 32), another significant benefit of strategic skill management is improve performance of employees in a dynamic environment and motivating them through designing performance incentives plans.

Another area of study that should be given attention in future, and one that attracts a lot of attention is the relationship between different initiatives in the industry and costs. Health care finance and economics as a challenge in skill mix is explained by different analysts who argue the need to address the issues of cost in the healthcare industry. According to Eastaugh (2004), although citizens benefit from developed healthcare and nursing structures put in place in different nations, the costs are uncomfortable for most tax-payers. Administrative costs are a major contribution to the high costs of healthcare. In many countries, it is estimated that administrative costs account for 6%-9% of the total healthcare costs. Administrative costs include salaries, payment for extra duties and other skill development programs. Future research should therefore focus on how skill mix initiatives can be used to minimize costs in the sector.


To sum up, skill development is a key determinant of how well a workforce in nursing care will perform. Skill development functions have to be performed and implemented effectively and pragmatically in nursing. As aforementioned, skill mix is aimed at initiating changes through substitution, diversification or other initiatives that ensure professional development. When problems in the sector are well defined and established, it is easier to apply skill mix in specific areas and use it as a viable solution.

Skill mix is required in the healthcare industry if it wants to develop and reap the benefits of available professionalism in the sector. The healthcare needs today are constantly changing and demands constant innovations and change of solutions. Skill care management features personnel administration, organizational management, skill management and professional development. As the medical professionalism gets more and more complex and the need for talent becomes more obvious for optimum performance, the sector is facing major challenges as the try to get the best in the market, retain them and ensure quality results.

As nursing practice further develops and becomes more competitive, especially in private practice, strategic skill management is a key recipe required when formulating effective professional development initiatives. The sector must be able to establish what works and what does not in order to eliminate those strategies that waste time and cost the sector. Another major challenge facing the sector is ensuring talented nurses and other medical professionals stay motivated and disciplined. This is increasingly becoming a concern as the public and private sector compete for the most skilled medical professionals in the industry.

Ensuring open communication channels between all the stakeholders is the first step towards identifying problems and implementing solutions. Incentives, recognition, rewards, and strict discipline measures are key strategies towards ensuring that medical professionals deliver, keep in line with the sector’s timeliness, and stay disciplined. When such measures lack, the medical sector’s efforts to develop the best skills in the market may not be rewarding.

Skill mix aims at assessing the nature of skills available for professionals, the expected results and actual results. There are three parts of skill mix initiatives namely; the purpose, return on its implementation and the most appropriate places to apply it. Skill mix constitutes the financial and non-financial aspect. However, it is important to note that skill mix is not just about skill development. It is also about other professional rewards such as ethics, which boost an employee’s ability and confidence. Key issues to address in skill mix include how to manage external and internal influences, as well as how to develop individual and team skills.

Skill mix in community nursing should address the most appropriate performance management processes for the healthcare sector, how power should be devolved to community nurses, and how they can manage their own skills development strategies while staying within the sector’s policies to allow every employee in every level is reached. It should also address how to structure and design job evaluation schemes. These will put into focus performance measures and what they are based on.

In today’s scenario, there are various skill mix trends available for the community nursing sector. In the healthcare sector, others choose integrated skill development structures that cover every employee regardless of their position. Skill development in community nursing should cover all the nurses regardless of the level of work or duration of experience.

Team development is a common trend today in most industries and more important is being able to deliver as a team. Having nurses with different qualities and professional capabilities at work makes it possible for them to deliver as a team. For those whose skills are more specialized, such settings allow them to perfect them. For those whose job positions require them to perform different responsibilities, skill mix will allow them to learn and expand the scope of the responsibilities they can handle.

Other benefits that will arise from skill mix in community nursing include performance awards and more sensitivity to functional skills to enable the sector retains talented employees. Building and developing skills ensures that nurses stay relevant in the sector. Through skill transfer, their skills are constantly updated and so is their knowledge of the patients’ needs. Performance is improved and functionality in increased. When they are able to perform, back each other up and deliver as expected, they are motivated to do more.

From the literature review, there are factors influencing the ability to scale up skill mix initiatives. One of them is contextual frameworks. The factors cover the influence of regulations and policies that cover practice such as education systems in different regions, professionalism as understood in them different regions, and statutory recognition of nursing in that particular region.

Skill mix serves a solution to several challenges facing the healthcare industry. It allows the development of new skills and ideas from each other, hence allowing people trained in different professions to build each other’s potential and capabilities. As result, there is more delivery of services with the available number of nurses available. Furthermore, it can be used to address the current increases in the cost of healthcare, an issue that is suggested for future research. A structure that allows skills growth will make it possible for nurses to focus more on major responsibilities and achieve perfection.

Another appropriate area where community nursing can benefit from skill mix and transferability is ensuring quality. Skill mix allows the sector to integrate quality improvement techniques through training, coaching, delegation and a properly balanced workforce. Training and skill transferability is aimed at preparing individuals to keep their skills updated and ready to undertake higher levels of work when chance arises. It also provides a possibility of performance change. Skill transferability will help the nursing industry retain their pool of human resource and stay up-to-date with current and relevant skills in the market. It also makes the nurses feel cared for and are then motivated to give better quality to their clients.

In conclusion, skill mix in community nursing will play a significant role in ensuring professional development. It plays a major role in skill transferability by allowing nurses to influence each other and teaching each other new ideas and skills. Developing community nurses skills allows them more efficiency in their supportive role to the physicians. Having a team of nurses with different skills allows more work to be done and patients with different needs attended to.

This research will analyze in depth the role of skill mix in skill and knowledge transfer by using research methodologies that allow an in-depth collection of information and data. These will include academic resources, statistics from different sources, and data from past research projects on the same topic from different authors. The most effective way to collect primary data in this survey will be conducting a survey on 15 participants. It will also be through interviews and discussions with a number of people chosen using a specified category. It is from the results that discussions and arguments will be developed. From the results, conclusions and recommendations will be drawn.


Skill mix initiatives in community sector should be able to identify which performance management processes are appropriate for it. The sector must be able to identify its needs and implement strategies that address them. Developing skills in any industry is a great way to ensure every employee benefits from professional growth strategies. Devolving powers in the sector is a good way to ensure that professionals in the industry can manage their own skill mix strategies while staying within the corporate policies. They are then able to reach every employee regardless of their level of employment. The human resource management department may not be able to identify, recognize and reach all employees in the sector. Community nurses have less contact with the human resource managers. Allowing them the skills and power to implement skill mix initiatives at their own level is a way to reach everyone in the sector.

Jobs designs should allow community nurses and other medical professionals working with them to accomplish their goals and targets. Undefined job responsibilities make it hard for employees and organizations to measure success. Evaluation schemes must also ensure that employees are tested on all relevant performance levels. They should test target deliveries, employee’s relationships with colleagues, and discipline levels among others. This way, skill mix becomes a comprehensive solution to most of the professional challenges facing the sector.

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Appendix I

Interview questions

Section 1
  1. Why did you decide to join the community sector?
  2. What were you doing prior to joining the sector?
  3. Did anything in specific motivate you to join the medical field?
Section 2
  1. For how long have you been practicing in the community nursing context?
  2. Why are you still in the medical profession?
  3. Do you consider leaving anytime soon?
  4. If you were to leave, what would be you reasons?
Section 3
  1. Are you familiar with the word skill mix?
  2. In your opinion, is it relevant in community nursing?
  3. What is its influence in community nursing?
  4. What is its role in skill transferability?
  5. Is skill mix a viable way of transmitting knowledge and skills among nurses?
  6. How does its implementation affect professional development among community nurses?
  7. If it was to be implemented effectively, what would be the short and long term benefits in community nursing?
  8. Are medical professionals supportive of skill mix in community nursing?
  9. Do you think stakeholders have done enough to get the best out of skill mix initiatives in community nursing?
  10. How would skill mix in community nursing improve performance?
  11. What is the role of technology in successful implementation of skill mix and helping community nurses benefit from it?

Appendix II

Budget for the research project

Budget for the research project

Appendix III: Literature review table

Appendix: Tabled Literature Review
Question or Aim Approach Subject & Setting Researchers Perspective Noted Methods Methods of analysis of data Results credible Conclusions
Buchan and Calman (2005) ‘Skill Mix and Policy Change in the Health Work force Skill mix in nursing practice Defining available skills in terms of settings and staffing I

Focused interviews

Content analysis Very credible Skill mix is important in nursing prsctise
Canham and Joanne (2002) Transferability of skill mix Skill mix in nursing practice Determining how skills can be transfered Focused interviews Content analysis Very credible Health professionals should encourage transferability of skill mix
Buchan (2004) Skill mix initiatives Skill mix in nursing practice How skill mix initiatives can motivate health factors Focused interviews Content analysis credible Skill mix initiatives should be implemented through trainings.
Cowen and Moorhead (2006) Healthcare policies supporting skill mix Skill mix in nursing practice How policies can influence skill mix Focused interviews Content analysis credible Healthcare policies should be able to regulate nursing practises

Appendix IV

Required materials

  • Questionnaires
  • A weblink
  • Detailed instructions of what is expected of the participants in hard and soft copies
  • A phone to contact interviewees and conduct some of them
  • Letters giving consent from concerned authorities
  • Investigative questions in hard copies and a soft copy
  • Venues where interviews will be conducted
  • Financial resources as outlined in the budget above