The human impact of having too few nurses
digest.bps.org.uk
digest.bps.org.uk
Another factor not mentioned here but which might be relevant, is that as long as nursing is undervalued (particularly economically, but in less tangible ways too) to the extent that the system is short of nurses, it is unlikely that employers would able to choose pick and choose better nurses from those available, and/or remove bad ones. It seems obvious from an organisational perspective that nurse > no nurse, but there's a direct link (in my experience) between the quality of care patients receive, and the attitude/experience/quality of the individual nursing staff.
There are strongly entrenched interests in the NHS which I suspect constrain relative pay between professions and grades much more tightly than they constrain absolute pay numbers.
COMPARISON OF PRIMARY CARE OUTCOMES OF NURSE PRACTITIONERS AND PHYSICIANS
https://research.libraries.wsu.edu/xmlui/bitstream/handle/23...
> Relevant Research Findings There are two landmark studies on the quality of the primary care delivered by nurse practitioners in regards to that of physicians. The first was by Mundinger, et al. (2000) and a follow-up study by Lenz, Mundinger, Kane, Hopkins & Lin (2004).
...
> The results indicated tllat there were no significant differences in patient outconles regarding health status, physiologic test results or health status utilization. Patients seen by NPs did have a statistically significant, but not clinically significant lower diastolic blood pressure (82 vs. 85 mm Hg; p==.04).
...
> The outcomes compared were health status, utilization of health services, and satisfaction with health care. The investigators found no significant differences in outcomes between the two groups, one seen by MDs and the other seen by NPs. The only difference in the results is the average number of primary care visits during year two for each discipline
> The study was a randomized double-blind trial to compare outcomes of patients assigned to either NPs or MDs for follow-up care after initial management at either an emergency department or urgent care clinic for asthma, diabetes, and/or hypertension.
This excludes what I originally meant to refer to, which is non-routine care. I am fully confident that NPs can handle routine care, what I was asserting is that they are (anecdotally) bad at handling more complex/infrequent issues
So, for example, I doubt that if NPs were specifically trained in specialty area X, you'd see any real differences. If we're going to do anecdotes, my personal experiences have been that the care provided by NPs (or PAs) has not been any different from physicians, even in relatively specialty areas I've dealt with. In fact, in some ways the care was better because we weren't trying to pressured into expensive procedures with absolutely zero scientific evidence of improved outcomes (having a hammer makes everything a nail).
What seems to be going under the radar is that the vast majority of MD programs are moving to 1.5 years or even less of academic training, with the rest being a variety of clinical experiences and quick rotations. This is fine, but what it means is that if you have a need for a provider in specialty area X, there's little difference between an MD + 4 years of specialty training, and something like a PA or NP + 6 years of training. We could get into discussions about academic preparedness, but at that point you're making a lot of assumptions averaging over individual variability, and ignoring things like nurses often having a ton of very technical training in actual physical technique.
I would love nothing more than for competition to open up dramatically in healthcare in terms of access, training, provider, and administrator models. This is happening to some extent now but it needs to be dramatically expanded. I see very little empirical or logical reason to assume that 4 years of general MD/DO training to something more specialized, is better than alternate training trajectories. Many of the professions in healthcare, such as nurses, PAs, pharmacists, psychologists, dentists, optometrists, etc. could be dramatically increased in scope of care, and new roles created that don't even exist currently, if there wasn't such territoriality and hierarchy in healthcare. Costs are spiraling currently in part because of rent-seeking problems. We've built our current system on a very dated set of stereotypes and outmoded assumptions, and are paying for it.
Also a lot more nurses; since with the baby boomer generation in and entering retirement the need isn't going to go down relative to historic levels.
* Edit:
By better quality of life I mean things like having a 4 x 8 hour shifts with each having about 2 hours of overlap for review of records, passing down, and filling out post shift paperwork. Yes nurses would need similar shifts, the overlap also gives time for the transfer of knowledge, in the process of getting it entered/updated in the health record systems.
Some locations don't allow nurses to unionize or strike. In AZ, for example, there's an inverse-union all the hospitals joined that member providers for staffing have to comply with contracted rates, etc. Which I don't know why it doesn't go afoul of the right to work laws here, I don't know (probably lack of prosecution).
In the end, it varies a lot and at some point there will definitely be more collective negotiation going on. Pay will have to go up in a lot of locations.
That said, it's true that nursing is relatively under-paid in the UK. Part of that however is because the state is the largest employer of nurses which keeps wages down but that in turn keeps the cost of healthcare down.
When your state only provides a minority of nursing then it has to pay higher wages to compete with the profit-driven sector.
But it's crude to say "Nurses make less than half than in the US", because so do software developers, but no-one's saying "think of the devs!".
I am fairly sure that if I moved to SF I would make 70%-100% more than I do in London, doing essentially the same job. In Poland if I had to guess I'd say a drop of at least half.
What is relevant is whether or not the salary is reasonable within the location.
It's more meaningful to compare UK nurse wages to other UK wages. That still shows that nurses are under paid but in a more meaningful way.
Of course the gulf between 30k and 78k is enormous but not many people in the UK are earning 78k, so it's really not meaningful to suggest that's what nurses ought to be earning, that would be in a small minority of earners.
Look how fast wages drop off around that level here: https://en.wikipedia.org/wiki/Income_in_the_United_Kingdom
The UK has an entirely different attitude to pensions than the US, and you could write a book about it, so it is hard to make a direct comparison because the expectations are so far apart.
The NHS seems to be capable of attracting nurses from overseas, in my local hospital you could speak Tagalog and get the same experience. The problem recruiting nurses into the NHS is the punitive visa regime, not monetary compensation.
The other part of it is that it doesn’t cost an arm and a leg to get a nursing license or degree in the UK, at least not as bad as the US.
I'd wager all those and more are generally a better in the UK and not all of them are quantifiable.
[1]https://www.gov.uk/government/publications/nursing-degree-ap...
I believe the immigration wave started after austerity measures were implemented in both countries.
Abstract:
Background- Existing evidence indicates that reducing nurse staffing and/or skill mix adversely affects care quality. Nursing shortages may lead managers to dilute nursing team skill mix, substituting assistant personnel for registered nurses (RNs). However, no previous studies have described the relationship between nurse staffing and staff–patient interactions.
Setting- Six wards at two English National Health Service hospitals.
Methods- We observed 238 hours of care (n=270 patients). Staff–patient interactions were rated using the Quality of Interactions Schedule. RN, healthcare assistant (HCA) and patient numbers were used to calculate patient-to-staff ratios. Multilevel regression models explored the association between staffing levels, skill mix and the chance of an interaction being rated as ‘negative’ quality, rate at which patients experienced interactions and total amount of time patients spent interacting with staff per observed hour.
Results- 10% of the 3076 observed interactions were rated as negative. The odds of a negative interaction increased significantly as the number of patients per RN increased (p=0.035, OR of 2.82 for ≥8 patients/RN compared with >6 to <8 patients/RN). A similar pattern was observed for HCA staffing but the relationship was not significant (p=0.056). When RN staffing was low, the odds of a negative interaction increased with higher HCA staffing. Rate of interactions per patient hour, but not total amount of interaction time, was related to RN and HCA staffing levels.
Conclusion- Low RN staffing levels are associated with changes in quality and quantity of staff–patient interactions. When RN staffing is low, increases in assistant staff levels are not associated with improved quality of staff–patient interactions. Beneficial effects from adding assistant staff are likely to be dependent on having sufficient RNs to supervise, limiting the scope for substitution.
> in the aftermath of austerity and with not enough staff to go round
Pay more, get more nurses.
Or you can trade-off nurses for less-good health care.
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Just to show an "existence proof" of an alternate universe, there are two totally free hospitals in India. They have no billing desk because they do not bill.
So how is it funded?
The people who work there and who support them financially believe that they are literally working for God. It is as if a Christian was volunteering to work at hospitals established by Jesus.
https://en.wikipedia.org/wiki/Sri_Sathya_Sai_Super_Specialit...
> The Sri Sathya Sai Institutes of Higher Medical Sciences also popularly known as Super Specialty Hospitals are tertiary health care hospitals established by Sri Sathya Sai Baba to provide patient care facilities to all irrespective of caste, class, creed, gender, religion or nationality totally free of charge.
Actually it's funded by the billions of dollars donated to his charitable trust.
> Just to show an "existence proof" of an alternate universe, there are two totally free hospitals in India. They have no billing desk because they do not bill.
That's not an alt universe, that's just free healthcare, just like in the UK, Fiji, New Zealand, and numerous other nations.
To me it seems impressive and wonderful that people have been inspired to contribute billions of dollars to support health care and clean drinking water and other charitable good works.
We're at such a state of technological advancement now in a place like the UK that we're essentially post scarcity. We need very few people any more to provide the basic building blocks of life.
In such a scenario, what we should be doing is taking advantage of that fact to distribute labour more appropriately - more hospital work, more social work, more housing, etcetera.
Instead what we have is seemingly some sort of race to put half the population on retail/delivery/general grunt work to please the whims of the other half, who don't actually end up happy because they're working their arse off and generally stressed by the lack of 'life infrastructure' as well.
How has this gone so wrong?
There is a limit to the number of people who are both able and willing to become nurses. Nursing is not just "looking after people in a hospital" - it's a highly skilled job which also entails a very high level of stress, and which nowadays requires a degree level qualification in the subject. The number of people able to do this job, including surviving the stress levels it entails over a whole career, is relatively limited.
There's also another aspect to it - historically, a large number of women who nowadays would train to become doctors (assuming they stay within the healthcare sector) were effectively barred by either explicit or implicit sex discrimination so went into nursing instead. That largely doesn't happen today, at least for those educated in the UK.
More pay might move the number willing upwards (especially for those who are already qualified but not working as nurses for whatever reason - full time parents, those taking other work etc) but the structural problem of "how many people are able to do it" will probably never go away.
Exactly: if you're smart enough to be an RN, and willing to get that much education, why not go farther with your education and become a doctor, so you can get paid many times what you'd get as a nurse?
It's just a smaller group now than it once was because the requirements for nursing have gone up and the discrimination which prevented women from becoming doctors has all but disappeared. Layer onto that the impact of broader opportunities for women outside healthcare (meaning fewer who are able to are willing to go into nursing) and there's a double impact.
If she did not face this constraint, she could have taken the traditional route of going to university and, possibly, becoming a doctor.
Legislating what humans are allowed to want and need and then calling that "post scarcity" has led to immense suffering over the past century. It continues to be a temptation of authoritarians who want a utopian society and want it now.
Perhaps you meant something else? Do you think if we just had more intelligent robots to do our work for us we wouldn't need to work anymore? I think it's impossible to do it with existing technology, although I wouldn't rule out future technology. This is where basic income enters the discussion as a bridge from scarcity to post-scarcity.
As an addendum, I believe we are approaching post-scarcity for a higher and higher percent of the population who are perfectly happy with what they have (this includes early retirement, financial independence, long sabbaticals, etc.). We are also approaching post-scarcity in some industries, such as software where the majority of it is "free", although of course "free" means different things to different people which is another discussion.
-- Russell, Bertrand, In Praise of Idleness (1932) http://www.zpub.com/notes/idle.html
Personally I think we need to dramatically reduce credentialism in health care, but we have to be willing to tolerate the occasional horror story that seems like it could be fixed by more education.
Anyways, my endocrinologist is a nurse practitioner with a masters degree. I have a very rare autoimmune neurological disease, that affects my peripheral nervous system, that was initially blamed on type 1 diabetes complications.
In fact, its onset was so insidious that it looked just like "diabetes complications." My endocrinologist (you know, the nurse practitioner with a masters degree) sent my blood to the only lab in the US that tests for the disease I have...and it came back positive.
The rest is really history, and now I am getting proper treatment for it.
source: nurse significant other having to tell better-paid (usually by a lot) newbie doctors what to do on the job
That's a complete non-starter in this day and age though. "Just one life" and all that crap. It's simply not possible to float the idea that taking on more risk (by employing less trained nurses) in order to bring some benefit to society (more nurse-hours available) may have an overall net benefit to society without be labeled a baby murderer.
And we train taxi drivers, and even lorry drivers, in a few days
People generally aren't going to rush to those kind of careers. Nursing is an exception, but it's a very demanding stressful line of work, where you have to filter out a lot of people to avoid serious, life threatening mistakes.
You state this as if it's some sort of unalterable truth.
We could produce a situation in which, right, you do social care, you get a home with a decent garden back and front. The sort of thing that happened en masse in the 60s.
We just don't. Not for lack of money, for lack of will, political, social, whatever it is.
It's exactly the same sort of problem that has highly skilled engineers wanking about making ads whilst they could be doing important R&D.
Long hours aren't inherent, they come about because of artificially produced shortages.
The seventies chaos stemming from 73 brought us to sorely needing some of the neoliberal, monetarist solution of Thatcherism. Everything had to pay, everything had to be reduced to economic choice. Mental health, happiness, social cohesion, community services etc were deemed unimportant. So we have very much reaped what they sowed.
The first ten years were probably helpful to correct the damage of the seventies. The next 30 have been making it worse. New Labour improved some areas markedly, but mostly kept pushing in the wrong direction. Health and social care is purely and solely a drain. Nurses are paid accordingly. No account is taken of the knock-on effects of a long waiting list or poor care taking someone out of the workforce far longer, or creating larger and longer term issues...
To my view of the world we are long overdue a correction.
There can only be so many 2 acre beach front houses near city X.
We make tradeoffs on these things -- now the one big problem is when people force that tradeoff on others. Like banning high density housing. If they want to buy all the land that's ok, but stopping someone else is fundamentally wrong.
The issue is more with the lack of decently sized and equipped flats, and terraced / semi detached family housing with small gardens reasonably close to transport links.
Scrap the high income cap on national insurance contributions and pay for the nurses!
Which is particularly funny, as immigrants are usually claimed to not take jobs from natives because they create demand, thus creating more jobs. Is nursing supposed to be an exception?
NHS is centrally planned, which explains some of the supply shortage and why demand-driven supply arguments don’t apply.
Employers pay 13.8% of all earnings above the "secondary threshold" with no reduction.
(There's a good case for effectively removing that 12% bit by moving up the point where you start to pay NICs to align with the personal allowance and for assessing NICs annually instead of weekly/monthly. There are also complicating factors like under 21s partly and over state pension age fully not paying NICs too).
I've also never heard a politician say that "mass immigration" is needed because of nurses, and indeed it would be not be most people's idea of "mass immigration" even if every single nurse working in the NHS were an immigrant - there are around 300,000 nurses working in the NHS.
It's a nice little tax dodge rich people get away with, then point at just the higher income tax without mentioning the massively regressive NICs.
Scrap the cap, most people won't be affected, new nurses, win.
Tax for the rich has been too low for too long in the UK and it needs to be increased. Scrapping the NIC cap is an easy way, with it being confusing enough that they can make it sound like there's no tax increase at all.
Instead, they're targeting self-employed and business owners with tax hikes on dividends in another, confusing, utterly stupid, shoot yourself in the foot move. Because the thing you want to do when the economy is sluggish is make it more expensive to run a small business.
From £50k-60k it increases to 49%, however if you have a couple of kids it increases to 65%. From £60k to 100k it's back down to 49%
Your proposal would increase single income households on average post-tax pay to a marginal tax rate of 80%. 95% if you include bsc/msc student loan repayments, and over 100% with 3 kids.
In the meantime millionaire pensioners sitting with twice the post-tax post-housing income are paying a marginal rate of 20%.
100 years ago a person with a failing heart might say "I have everything I need in my life" and die without getting a transplant.
That won't happen today.
People keep producing more because they want more.
Hindsight? Care to take a crack at the complex socioeconomic issues that will exist in 50 years arising from technology, infrastructure and social dynamics that haven't been invented yet?
This is not a technology or advancement issue, it is about our society's values. One of the characters, the rich banker, is described over and over as being able to justify in himself that he disagrees with. That is being a human, that is the source of these types of challenges. "I want it because... I want it, and if I have the means then why wouldn't I take it?"
However, we learn from history that we do not learn from history.
It's predominantly a public sector thing.
Precisely - the issue is that this is a flawed voting mechanism.
I have more money than most people in the UK. There are a whole host of reasons for that - some hard work, but a lot of them essentially random/arbitrary.
As a result, I have the power to hire people if I so choose. In a smaller sense you're doing that any time you spend money.
But in an unequal society, that means that the majority of decisions end up being made by a small elite.
I'm talking about the jobs that actually get done. Not every task that a human (or robot) performs as labour is essential. For the most part, the human ends up doing the thing that pays them the most.
It's not necessarily the case that the thing that pays them the most is best for society.
Imagine that, for example, building video games and being a nurse are both non-automatable tasks and both have no upper bound.
Let's assume building video games is a higher paying job.
It's not necessarily the case that a person who can do both should do that. It may be in their own interest and the interest of their employer but not wider society.
Not to mention that Poland already has low number of nurses for its population.
If you want to study how bad it can be keep an eye on Poland.
I don't see this as being entirely a bad thing. While nurses and other caregivers can be an important source of human contact for the sick and elderly, caring and being cared for by another person can be an emotionally and physically fraught and draining process. If we can build automated systems that allow baseline physical and hygienic needs to be met, even for the frailest and sickest people, I think that had to be good for the mental health of both those needing care, as it will reduce their sense of being a burden, and on the caregivers themselves, as they will be able to focus on the most important quality-of-life issues instead of being stuck on a treadmill of providing basic care.
If you look at it as a cost, you will attempt to minimize it.
If you look at it as a benefit, you will attempt to maximize it.
The State looks at healthcare as a cost to be minimized. The State does not get sick or need healthcare.
Likewise, employers also look at healthcare as a cost to be minimized, but they do have some motivation to provide better quality insurance if they wish to attract employees.
Only you, the potential patient, really care about the benefits side of healthcare, and the quality of healthcare.
Health insurance has been screwed up by having the State and/or employers provide it for decades. What is required is for people to be able to purchase health insurance themselves just like they do any other kind of insurance. That would be a start anyway.
To be fair, they acknowledge their limitations and the fact that they can't make a causal interpretation. (Bad hospitals -> nurses leave?) But why the hell design the study this way?
One could introduce a fee of say 20 pound pr. visit. Something that is low enough that anyone in UK could pay it but also high enough to remind people that what they are consuming is finite resource.
That breaks when people can pay in real money. Since the system is supply constrained all that does is reserve scarce medical resources for those with money rather than those with the most need. It allows rich people to jump the queue - just like the 'VIP' lane at a theme park.
Queue jumping in the UK was always frowned upon. The ultimate social faux-pas. That seems to be weakening in recent years and the 'time as money' system is weakening with it.
Can you elaborate here?
The problem is with such things that they're regressive taxes. Rich people can still afford to go to the doctors when they have a sniffle but poor people will re-consider even when they have a life-threatening illness because £20 is a months food bills for the poor person.
Tolls on a congested bridge are "regressive" but are practical and make sense. We shouldn't structure society around what makes things less convenient for the rich, there just isn't very many of them by definition. We should structure society around what improves the lives of most people, within the current realities that exists. This is the classic sin of envy where we'd actually rather be worse off if the person we envied was also worse off.
Now maybe there are other reasons to avoid co-pays, such as higher death rates in areas with co-pays. I'd be interested to see a study that demonstrated the tradeoffs of co-pays.
What's a copayment?
There's no evidence it would work. There's some evidence it wouldn't work.
Don't forget this study was done in in-patient settings: those patients were actually ill and needed treatment.
A prescription charge doesn't work in quite the same way because if you are getting a prescription then you already know you need it, unlike going to the doctor.
This would necessarily have to function identically.
If there aren't enough nurses for the sick people, we need more nurses. We can't control the number of sick people by excluding the poor.
The whole system amazes me all the time. We have the people who need to think very clearly and be very awake do 18, 24 and more shifts. That doesn't sound like they'd be at peak performance at all times.
They're not.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200708/
> Health care workers need to begin to think of coming to work impaired by chronic sleep deprivation as similar to coming to work impaired by alcohol. Studies reveal that as ethanol and sleep loss increase, psychomotor performance decreases and memory is impaired. A 2-hour sleep loss is equivalent to a 0.045% breath-alcohol concentration, and a 4-hour sleep loss is equivalent to a 0.095% breath-alcohol concentration — above Texas' legal limit of 0.08%.
> In the traditional-schedule group, interns were on call every third night, working 24 hours or more. In the intervention group, interns worked no extended shifts (>17 hours) and averaged 65 work hours each week. Besides having about 6 hours less sleep each week and twice the number of attentional failures (EEG evidence of severe drowsiness), the traditional-schedule group made 36% more serious medical errors than the intervention group.
Nurses start at band 5 of the agenda for change pay scale, or band 6 if they're specialist, so it's not much but even this is unattainable for most NHS trusts. https://www.nhsemployers.org/pay-pensions-and-reward/agenda-...
When we ask nurses which shift pattern (8 hours, 12 hours, or 14 hours) is safest they tend to say 8 hours. But when we ask them which provides best work-life balance they tend to say 14 hours. This is apparently a really difficult problem for the workforce to tackle.
Do they have to go home?
Special rules to allow them to stay?
Hospitals don't want to hire nurses because it loses them money. They only care about staying at the federally-mandated minimum staffing ratio, which they can skirt by only staffing adequate numbers when the oversight agencies come around. Seems like this is happening in every industry - CS appears to not want to hire either unless they absolutely are forced to fill a void. They'd rather just have one person do the work of two people since that person won't be able to find a job elsewhere anyway.
In 2007, before the crash, after 10 years of New Labour, the U.S. spent 15% of its GDP on healthcare. German 10%, the Netherlands 9%.
The UK spent 7.4%.
In fact it's over the last 10 years that the UK has begun to catch up with the rest of Europe.
Netherlands 81.6
U.K. 81.2
Germany 81.1
USA 78.6
https://data.oecd.org/healthstat/life-expectancy-at-birth.ht...
https://www.gov.uk/guidance/immigration-rules/immigration-ru...