Nursing is once again on the occupational shortage list and the solutions are far from perfect.
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Each one bears a financial cost, and places increasing pressure on senior staff to manage temporary nurses, accommodate those from other countries, or bear the brunt of staffing shortages themselves. Increased pressure leads to sickness, absence, higher burnout, and staff leaving. And then we have more vacancies and pressure. It is a downward spiral fuelled by too few registered nurses.
In December Health Education England published the national workforce investment plan. Confusingly, given the context of too few RNs, just 300 additional adult general nurse training places are to be funded – only 10% of the number that had been calculated as needed. In the same month the nursing associate role was announced, to increase the capability and capacity of the nursing workforce. It is not intended to substitute RNs, but to complement them. But consider how its introduction might work in practice.
Clover Ward, a 30-bed acute medical ward, has 30 RNs and 15 healthcare support workers (determined by professional judgement and the Safer Nursing Care Tool, an NHS web application used to determine optimal staff levels). All the HCSWs posts are filled but 10% of RN posts are vacant. Then comes the plan to introduce nursing associates. How might this establishment change?
● More money is provided for Clover Ward to have two nursing associates on top of the funded establishment, to free up RN time. This is unlikely.
● HCSWs are funded to be trained as nursing associates, increasing their skill level. But Health Education England says employers have to fund education.
● Finally, trusts say: “We can’t wait to recruit RNs; we’ll switch those vacancies into nursing associate posts. We need the staff now and it’ll be cheaper too.” Plus it will stop RNs being “dragged down by fundamental care”, as the HEE puts it.
Which of these is likely to happen? In the current financial context only option C is viable. If we introduce the nursing associate role with the existing budget, it can only be as a replacement for RN posts, because everything else costs money. And so the nursing associate will sometimes be used as a substitute for RNs.
Patients will receive more care from staff who have had less training. But this isn’t a nursing issue. It is a fundamental issue about the level and quality of care we as a society want to be available to patients when they receive care in the NHS.
Insufficient investment in training enough RNs got us into this mess. Investment in the workforce is the only way out. Having established the number of RNs needed, we need to train and employ them, without compromise. Low RN staffing levels causes patients to die in hospital. And 86% of RNs leave necessary care undone because they haven’t enough time.
If there isn’t the money in the system to provide the current range of services safely, then reduce the services. Close beds. Charge for some elements of care. Put a penny on the taxes of higher paid to create a safer care fund. Shift the balance of funding so a higher percentage goes into nursing workforce rather than medicine.
I don’t know which of these options is the right. I’m not a policy maker. I’m not a health economist. Nor am I a politician. But as a researcher with 20+ years’ experience of studying the nursing workforce, I know that if we want a healthcare system that provides care safely, these choices need making. And then we can once again uphold the first principle of medicine and nursing: do the patient no harm.
Jane Ball is Principal Research Fellow NIHR CLAHRC Wessex, University of Southampton