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Substitution in nursing practice: clinical, management and research implications.

The introduction of market forces into health care delivery systems has had a number of important influences on the roles nurses perform. There have been increasing efforts to find alternative and more cost-effective ways of delivering care. One facet of this situation has been the examination of the roles and responsibilities of registered nurses (RNs) with the view of exploring different ways of using professional skills and determining if RN services are always required. One result of this has been the increased use of unlicensed personnel. The substitution of professional nursing staff by unlicensed personnel has become a major concern for practitioner, manager and client alike. This paper reviews some of the concepts of economic substitution as well as the assumptions advanced for the use of unlicensed personnel in clinical areas as a substitute for nursing services. While there has been increased use of unlicensed staff, the evaluation of clinical outcomes has been poor. This paper reviews primarily the hospital-based evidence about the impact of using unlicensed personnel in practice, and suggests there are methodological problems with the research published to date. Findings suggest that substitute service providers generally 'do no harm'. By contrast, evidence is presented indicating the major contributions nurses make to client care when adopting advanced practice roles (acting as a substitute for other professionals).