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Sunday, 1 October 2017

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.

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