Nursing by numbers - what's the answer?

What is the right nurse -patient ratio on a ward; for a caseload in the community; as a nurse specialist for diabetes or cancer? Of course, the answer depends on so many variables: the skill and expertise of the nurse; the needs of the patients, their age, capability, emotional distress, whether there have several or just one condition that needs care and attention. And increasingly, whether there is a friend or relative close by able to help and support.

 

What we do know is that there are not enough nurses. Poor workforce planning over many years means that, according to the RCN, there are already around 24,000 vacant nursing positions in the NHS and post Brexit we could see a potential shortfall of 40,000. More than 2,700 nurses left the NHS in 2016, according to freedom of information requests compiled by the Liberal Democrats – an increase of 68 per cent since 2014. According to the Health Foundation, half (49%) of nurses don’t think there are sufficient staffing levels to allow them to do their job properly. 

This together with the loss of nursing bursaries which has caused a sharp drop in student nurse applications means that decisions about how many patients should be cared for by one nurse in hospital are likely to be flexed to what is possible rather than what is safe. Discussions have centred around one nurse to eight patients – doable if all patients are reasonably well and mostly self-caring. Quite impossible if they are all fully dependant. Australia introduced nurse patient ratios in 2015; whilst there are variations depending on the type of hospital, in general the numbers are one nurse to four patients with one nurse in charge; one nurse to eight patients at night.

In England, to try and combat the nursing shortage, the government has introduced the idea of nursing associates which, if you trained as a nurse many years ago you might recognise as a new version of enrolled nurses – often highly skilled people who did two years training instead of three and were relied upon to deliver the same quality of care as registered nurses but paid less and had no clear career path. Most ‘converted’ at a later date to be RNs in order to progress. We could end up in the same situation with nursing associates.

The erosion of pay means that nurses at Agenda for Change band 5 and above will have seen their pay cut by 12% in real terms over the decade from 2010/11 to 2020/21. Another reason why it is proving difficult to recruit to the profession.

Apart from numbers the other big issue that gets overlooked is the increasing complexity of nursing. It is a job that requires thought, planning, knowledge, diplomacy and intelligence, speed and agility of decision making and yet it is poorly regarded. Nurses themselves are often deprecating about their work, remembering only the drudgery and not crediting themselves with their plate spinning ability and skilful management. Nursing is not simply a series of tasks. It is complex and its contribution to the service and to patients individually needs much better recognition inside and outside of the profession.

The Health Select Committee will look at the current and future scale of the shortfall of nursing staff and whether the Government and responsible bodies have effective plans to recruit, train and retain this vital workforce.

This inquiry will assess the impact of new routes into nursing (including student funding reforms, the Apprenticeship Levy, Nurse First and nursing associates). In particular the inquiry will examine the effect of changes to funding arrangements for nurse training, including the withdrawal of bursaries, and consider alternative funding models and incentives.

The Committee would like to receive suggestions for how policymakers could optimize the potential of new routes into nursing, as well as how they might retain and deploy existing staff more effectively. 

However, the Health Foundation is clear that no one profession should be picked off on its own. It is the combination of different roles and skills that creates a good health service. Proper workforce planning is required that looks across different staff groupings to evaluate impact. 

This requires more than looking at nursing skill mix which too often means wards are polarised between untrained nursing assistants carrying out increasingly skilled work and RNs distanced from the caring element of the job.

Challenging images of nursing

The image of nurses – that old chestnut or should I say sexy stereotype – has been back in the news again. A group of well intentioned men dressed up as nurses to raise money for their local community health trust.  But the Trust rejected the £2,500 on the grounds that their actions were “...wrong, outdated and insulting to the profession”.  The fundraiser is an annual event in Ludlow, Shropshire, raising money for the NHS.  I have some sympathy with the men – they meant well and let’s face it as they said, this has been going on for 30 years and they’ve not had any complaints.  Oh no. Stop there, something that’s been going on for 30 years is probably long due an overhaul and the age old (sorry!) ‘had no complaints’ argument is one that Everyday Sexism Project and every woman will be familiar with.

It’s laudable to raise money for the Trust’s ECG equipment but really, is there any need for men to dress up as female nurses? There are myriad ways of raising money that could be just as or possibly more effective. “We’ve always done it this way”, doesn’t make it right. However, on the other hand my reaction to this particular sort of drag humour is that it is funny because of how ridiculous the men look as they deliberately ineptly try to wear women’s clothing. I object far more to serious television dramas that depict nurses with dresses just a little too short, or wearing heels; and of course with nothing sensible to do or intelligent to say.

Rituals and Myths in Nursing will explore some of the traditions behind nursing uniform – it’s military history reflected in the badges, buckles and starch – as well as exploring the mythical view of nurses as angels and/or sexual objects.

 A recent study by Emeritus Professor of Nursing at Oxford Brookes University, June Girvin and colleagues, explored the contemporary public perceptions of nursing. It identified four main themes:

1.     Media portrayal of nursing as a troubled profession

2.     Entertainment value in demeaning nursing

3.     Role of incongruity – nursing trusted but not respected

4.     Nursing roles remain poorly understood

The systematic review examined papers from January 2010 to September 2015 so at a time of high profile failures in hospital care, which will no doubt have coloured some of the reporting. However, the media is fairly negative about nursing depicting it as a ‘troubled profession’ for example, portraying the move to higher education negatively. This debate has raged since Florence was a girl as if education is a ‘bad’ thing for nurses (and in such a female dominated profession, I think, by implication, women in general). Indeed, schools and parents in the UK do not encourage students into nursing – they are much more likely to in the US where nursing has a better profile.

In film and social media, attractive, successful, intelligent and educated women were seen as incompatible with nursing.The study found that gender prejudices remain prevalent in the public image of nursing – female nurses portrayed as sexual playthings; male nurses still, in the 21^st century, characterised as effeminate.

Despite this the public generally have a positive perception of nursing but not surprisingly have little understanding of the complexity and diversity of the role. I think they are not alone. Nurses are poorly supported in their learning development. Paying for their own professional development is standard and very often they attend any educational or training days in their own time. It is a simple step from here to understanding how easy it is for nurses to be so poorly paid and why they have seen their jobs downgraded.

This attitude to nurses, so often served out to teachers too (another female dominated profession) needs to be challenged. All too often it is dismissed as either about nurses or about being female and actually it is both those things that cause nursing to be so badly treated. Challenging stereotypes as Shropshire community health NHS trust has done is an important public step. It's a shame that the Royal College of Nursing apparently decided not to comment.  This is where the immense reach it has as a union could have been put to good effect. Scrap the Cap doesn’t tell enough of the story. The profession needs to demonstrate strength, depth and challenge on all levels.

Researching custom and practice

Researching a book is, as any author will tell you far more enjoyable than the actual writing of it. You can go off on all kinds of tangents and find out fascinating facts that may or most likely may never appear in your book. There is also the opportunity for  self indulgence and I have loved the chance to enage in a little reminisience of nurse training days.

In pursuit of insight and knowledge for Rituals and Myths in Nursing I recently visited two very different nursing museums at two prestigious London Hospitals. St Thomas’ Hospital’s Nightingale Museum gives you all the low down on Florence – some 3000 artefacts relating not just to her work in the Crimea and her drive to establish nursing as a respectable profession in the UK but also to her family and childhood. The museum opened in 1989 on the site of the original Nightingale Training School and, thanks to the diligence of matrons and others over the years much memorabilia has been saved for our interest and enjoyment now.

For me, the most fascinating Florence fact I learnt is just what an amazing architect/statistician Florence was. Never mind the nursing rules and regulations she set out in Notes on Nursing: What it is and what it is not. From her detailed scaled drawings of what was to become St Thomas’s hospital, down to the exact distance each bed on a ward should be from other for optimum health are something that should be heralded as truly ahead of her time.

St Bartholomew's Hospital Square

On the north side of the Thames overlooking the beautifully restored 18^th century square designed by James Gibbs at the Royal and Ancient Hospital of St Bartholomew is the Bart’s museum . Small but packed with medical and nursing artefacts, the Bart’s museum is more intimate than the more sophisticated Nightingale museum offering less about the broader history of nursing but imbued with the very essence of what it is to have been a part of the hospital at any time in its history. It is not just my personal allegiance to the hospital – once a Bart’s nurse always a Bart’s nurse – but there is a warmth to the exhibition that is welcoming and friendly.

St Bartholomew's the Less

Visiting a museum that is at the very heart of the hospital gives the visitor an opportunity to see other things. Top amongst the Bart’s exhibits are the two magnificent William Hogarth paintings which hang on the staircase to the Great Hall and can be spied from the museum. But for me it is the tiny chapel of St Bartholomews's the Less that is just a few steps from the muesum, with its stained glass window commenorating the work of nurses during the second world war that is particularly special. 

Inside the museum I rather like the intriguing notes and records of weird and wonderful operations, photographs and records of stern looking matrons – Miss Gordon Fenwick (later Mrs Bedford Fenwick) who successfully fought for nurse registration for instance - and mutton chop whiskered surgeons with grand names recognisable from the wards once named after them: Percival Pott, William Harvey, Thomas Vicary. It is also rather strange to realise that history can feel very recent. A friend of mine was startled to see a replica of the uniform she wore in the 1970s at St Thomas’s showcased as a historical artefact!

As we grow older, history comes into focus. We want to put a marker down for where we were in the passage of time recognising that some of what we see even in our lifetimes future generations will consider remarkable. Medical advancement over the last century has been phenomenal and while ritual and myth still exist in nursing, there is less that is ritualistic as the work is ever more evidence based and the role highly technical.

Nurses are still required to be all things to all patients but their level of technical expertise is greater than a generation ago. A requirement that has largely gone unrecognised by the public, the politicians and perhaps by some of the profession itself. The custom and practice of nursing is certainly changing.

Celebrating history; fighting for a future

Westminster Abbey was packed with nurses, many were in the superbly uniformed ranks of service men and women but there were also nurses from every civilian rank and file: care support workers through to the chief nursing officer for England, Professor Jane Cummings.  The woman next to me was limbering up with gentle humming under her breath, familiarising herself with the hymns in the service sheet. The ladies the other side of me and all around were chatting to each other and some were calling out as they spotted old friends. 

This was my first time at the annual service to commemorate the life of Florence Nightingale. Speak it quietly but I’ve never been a huge fan of Florence and have always felt she has been heralded in the public eye to the exclusion of some other pretty amazing nurse leaders (Mary Seacole, Edith Cavell, Ethel Bedford Fenwick, to name a few).  But, as I am writing a book on the Rituals and Myths in Nursing, I was intrigued to witness this ultimate ritual in the nursing calendar: the celebration of Florence’s life.

As you will know, Florence was known as the ‘the lady with the lamp’, during her work in Crimea, and a lamp is kept in the Florence Nightingale chapel (yes really) at Westminster Abbey. The lamp was carried in procession by a Florence Nightingale Foundation scholar Sandra Mononga and the Lamp party was escorted by student nurses and midwives from Edinburgh Napier University, dressed in white uniforms and hats. The ceremony involves a series of processions through the Abbey to celebrate nurses who have served and continue to serve. First off were the Chelsea Pensioners – taking part in memory of Florence and her care of the troops – their predecessors – during the Crimean Campaign. Honorary officers of the Florence Nightingale Foundation were followed by the masters and warden of the newly formed Guild of Nurses and after that were a stream of nurse representatives from the many and varied corners of nursing and the armed forces.

The service is supported by the Florence Nightingale Foundation (a ‘living memorial to Florence Nightingale’). The service is held as close as possible to 12^th May – Florence’s birthday and now International Nurses Day. This year there was a bit of a clash: for the ceremony was held on 17^th May which coincided with RCN congress, both huge events in the nursing calendar. The story has it that the RCN president, Cecilia Amin, had to hotfoot it down from Congress in Liverpool to attend the hour long ceremony at Westminster Abbey.

Of course there were more than enough nurses to go round for both events with plenty others still on duty. According to Statista the statistics portal, there are 675,000 nurses in the UK and that doesn’t, as far as I can ascertain, include the armed services. Yet, still wards and services are short staffed.

For me, the clash of dates brought into focus the very different facets of nursing and nurses. On the one hand at Congress nurses were fighting to be heard by politicians and public alike: concerns about pay restraint, loss of real term income, nursing bursaries and shortage of skilled nursing care in every aspect of the health service. Whilst at Westminster Abbey, nurses were celebrating the art and science of what makes nursing good, away from the daily grind of long hours and poor reward. 

Whilst Labour leader Jeremy Corbyn and Lib Dem leader Tim Farron appeared at Congress to promise the kind of basic improvements in pay and conditions that nurses are desperate to see, the Conservatives saw no point in being targets for metaphorical if not actual egg throwing. The Tories know that the public still does not grasp how poorly recompensed nurses are and that the power to change this and how the NHS is regarded lies with their vote. And perhaps even politicians could see the hypocrisy in attending an event to celebrate the very foundation of nursing when as leaders they appear so unconcerned for the profession's future?  

Nurses’ pay has been relentlessly held back. The 1% cap is eroding nurses’ pay now and in the future. It is the reason that nurses are using food banks, no more complex than that. This, together with an overall shortage of nurses, downgrading of posts, loss of the nursing bursary and a political failure to actually care, means we are headed to months of disruption and potential strike action amongst a dedicated long suffering workforce.  My guess is that the politicians will ride it out, just like they did with the junior doctors. Short term success, being the only show in town because that sets the scene for longer term demise of a service that people will only value once it has gone.

As the woman next to me in the Abbey launched into the first hymn with a deafening but fortunately, tuneful voice, I realized that in reality these two celebrations were one and the same: Congress being the current vociferous call for action protecting the ancient bedrock of nursing, the history of which was being celebrated in the Abbey, both reminding us of the values and commitment of nursing’s predecessors and the fight that is on for its future.