IMPACT OF NURSE-TO-NURSE TECHNICIAN COLLABORATION ON CARE QUALITY AND CLINICAL OUTCOMES IN INTENSIVE CARE UNITS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

Background: Registered nurses in intensive care units (ICUs) increasingly use nursing/patient-care technicians and other unlicensed assistive personnel (UAP) for direct bedside care amidst workforce shortages and escalating patient acuity. To what extent the quality of registered nurse-technician collaboration is linked to quality of care and clinical outcomes in critical care remains un synthesised. Objective: To systematically review and narratively synthesize existing evidence regarding the association between nurse-nursing-technician (RN-UAP) collaboration, the quality of delegation to, and skill-mix with UAPs, and associated care quality and clinical outcomes in adult and neonatal ICUs. Methods: Following PRISMA 2020 guidance, a search of MEDLINE/PubMed, CINAHL, Scopus, Web of Science, and Embase was performed for articles published between January 2020 and February 2026, with supplementations by reference list scanning and grey literature search. Eligible articles had to evaluate RN-technician/UAP teamwork, delegation or skill-mix, and have measured at least one care-quality or clinical outcome in critical care or similarly acute care settings. Two pre-2020 cornerstone studies were included to provide historical context and theoretical frameworks. Data was extracted into a 20-study matrix and appraised using the Mixed Methods Appraisal Tool (MMAT). The high degree of clinical and methodological heterogeneity in exposure and outcome definitions prevented pooling across the entire evidence base; consequently, data were synthesised using narrative techniques and vote counting. For one outcome category where independent effect estimates were reportable – mortality associated with staffing/skill mix – an exploratory random effects meta-analysis (DerSimonian-Laird; k=3) is presented separately but in addition to the narrative synthesis. Results: Twenty studies were included (11 quantitative; 6 qualitative; 3 mixed methods/scoping or policy analytical) from Australia, the USA, Iran, Egypt, South Africa, Italy, Sweden, Germany and a multi-country report. Higher RN skill mix and better organised RN technician delegation were associated with better outcomes across most areas, including lower mortality, delirium, and pressure injury rates, reduced missed/rationed nursing care, and more positive team climate. However, the effect sizes, definitions, and significance of these associations varied, with some non-significant in adjusted models. The exploratory meta-analysis of 3 staffing/mortality studies demonstrated a pooled odds ratio of 1.19 (95%CI 0.96 1.49; I2=71%) for adverse outcomes associated with worse staffing/lower skill-mix, a finding consistent in direction, though not statistically conclusive and heterogeneous in definition. Role ambiguity, inconsistent delegation practices, and breakdown in communication were the most frequent mechanisms of harm identified. Conclusion: Despite the heterogeneity in the available evidence, current findings suggest a beneficial association between organized RN-technician collaboration and the quality of care and patient outcomes in critical care settings. The exploratory pooled mortality estimate supports this conclusion but is not conclusive evidence of such. Further research employing a robust methodology with consistent outcome definitions in RN-technician dyads, followed by a sufficiently powered and consistent meta-analysis, will be necessary for more definitive conclusions.