Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Gizzajob
- Susa LYTH (6 September 2002)
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Retention difficulties within the NHS
- F David Beggs (6 September 2002)
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Leaving the NHS
- Janet M Pinder (6 September 2002)
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A solution staring us in the face?
- Steven J Lewis (7 September 2002)
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Modernisation may be both problem and solution
- James F Munro, Alicia O'Cathain (9 September 2002)
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Why do midwives leave?
- Penny Curtis, Linda Ball and Mavis Kirkham (17 September 2002)
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Nurses' loyalty may be underestimated
- HEATHER M GAGE, Rosemary Pope, Fiona Lake (7 October 2002)
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Australia's nursing crisis - Flying away, not walking.
- Phillip J. Colquitt (9 October 2002)
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Susa LYTH, Housewife N/A CH7 6 PY
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Re. your article 'Mind the Gap'- my daughter has just qualified as RGN at North Wales School of Nursing and has no job to go to apart from an unconfirmed offer of a part time temporary post to cover maternity leave. This after struggling as a 31 year old single parent of 3 children on the pitiful bursary for 3 years. I might add that she was not impressed with the P2000 course content and organisation either. She lives on Anglesey and is therefore limited with choice, there being only one acute DGH within commuting distance. My daughter is now talking about taking a job at Tesco - I know several of her fellow students are in the same position. It's not all about money and housing, a lot could be attributed to poor local management and planning. Mrs Susan Lyth |
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F David Beggs, Consultant Thoracic Surgeon Nottingham City Hospital, NG5 1PB
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The authors are to be congratulated on their timely highlighting of problems in the retention of staff in the NHS. It must come as no surprise to those of us working within the NHS that 30% of newly qualified nurses appear to not bother joining the register and working within this new "Modernised" Health Service. What is surprising is that it has taken so long for this to become apparent or that there are many other Health Workers who turn their backs on their chosen profession shortly after qualification. The majority of workers within the NHS feel undervalued, overworked and abused by a Government whose main message appears to be that these workers, who for years have devoted themselves to an under resourced and badly run NHS, know less well than newly elected politicians how they should perform their duties. In addition, for every emotive incident within the NHS, there appears a whole industry dedicated to finding, humiliating and destroying a scapegoat, usually a health care professional. The Government, usually the Secretary of State, adopts the role of innocent patient advocate and the legal profession grow a little richer. Those who qualify in Nursing, Medicine and a host of other health care professions have already demonstrated their intelligence, application and dedication to the sick by undergoing a usually arduous professional training. Many then face slightly insulting inquisitions about their HIV status and possible criminal record. Finally, armed with their idealism they may join a crumbling edifice typical of most NHS Hospitals where they are expected to both try and do their job, and to respond to hostile enquiries brought on by the unreasonable expectations encouraged by Government dogma. Of course we are not all perfect; mistakes can and do happen and inevitably some are tempted to abuse the system in which they work, for personal gain. When these instances are brought to public attention, the Spin Doctors are wheeled out, Mr Milburn puts on his enraged face and a few more millions can be wasted correcting a minor problem. If someone can be pelted with eggs on the steps of the GMC or some other professional body and have their pension threatened, so much the better. On the other hand, when billions are lost on the Stock Exchange or some dodgy Insurance deal, the destruction of lives and consequent sickness or death appear to be accepted as due to market forces, or someone else retires with a golden handshake.Within this context, is it any surprise that the intelligent and the dedicated, with good interpersonal skills and qualifications elect to move into other jobs with better pay and conditions? At present there appears a shortage of nurses (and others) who wish to work in the NHS. Looking at the current NHS and, in particular, at Government "reforms" one can have every sympathy with those who wish to and who can get out. Poor pay is often cited as the problem and this is undoubtedly another factor. Recent supposed pay increases (up to 20% for Consultants widely announced by the media!) have all been associated with conditions attached and the realities have been, at least, much less attractive. Take a look around where you live and see who has the big house, the fine furniture, the new large car and the trips abroad and then decide for whom you would rather work if you were embarking on a career. How many of these got their lifestyle working for the NHS? I am afraid that the idealism that fired us in youth is less obvious as we approach retirement. Undoubtedly the new generation question whether they wish to follow in our foot-steps. Better options are available for less dedication and, until this is corrected, the difficulties will escalate. |
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Janet M Pinder, Medical Litigation Executive Russell Jones and Walker, Sheffield
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I have worked as a nurse in the NHS for 18 years, 15 years of which have been in A&E as both a staff nurse and a sister. I have encountered a lot of violence and aggression within this time from patients. Following a very frightening assault on me in which I was jumped on from behind, beaten over the head with a telephone and strangled I became concerned about my safety and that of my colleagues. I voiced my concerns to the management and stated that I did not feel that I could carry on working in A&E unless we were provided with full time security. I was told that this cost could not be justified. I therefore resigned my post and left the NHS as soon as I was able to secure a position. I have found that there is life outside the NHS where my work is appreciated by both my managers and my clients and where my opnion is both sought and valued. I was (and still am)a highly qualified A&E nurse and Emergency Nurse Practitioner but nothing could now compel me to return to the NHS. I would advise anyone thinking of starting their nurse training to think again. |
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Steven J Lewis, Adjunct Professor of Health Policy 3330 Hospital Drive NW, Calgary AB Canada T2N 4N1
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Finlayson and colleagues have admirably chronicled the problems affecting nursing and the environmental factors contributing to the current shortages. However, embedded in their story is a crucial element of the problem: "Evidence from the United States, Canada, and Germany found that nurses were spending time performing functions not related to their professional skills, such as cleaning rooms or moving food trays. Nurses also reported more pressure to take up management responsibility, taking them away from direct patient care." This suggests that while we may have a shortage of professional nursing, we do not necessarily have a shortage of nurses. The findings of Aiken et al. reflect those of many published and unpublished studies of how professionals spend their time. Put simply, nurses spend much of their time doing things that should be delegated to others and not enough of their time doing what they are educated to do. Not only is this inefficient; it is also demoralizing, and doubtless accounts for at least some of the widespread job dissatisfaction in the profession. Thus far policy responses have come in one of two forms: raising salaries (the strategy of choice in Canada in recent years), and increasing nursing education program capacity (favoured in many jurisdictions). Paying nurses more money may be just, but it will not by itself produce more nurses or make them more content with their working conditions once the transitory glow of the extra money dims. And increasing the supply of new nurses may turn out to be perversely ineffective if overall numbers grow, nurses perform even more non-nursing tasks, and system costs rise because highly-trained people are used inefficiently. The situation is by no means restricted to nursing. A recent BMJ systematic review (1) reported that nurse practitioners have demonstrated their capacity to do what general practitioners typically do in a wide variety of settings (1). In health care, it has proved extraordinarily difficult to get the division of labour right, and the complex array of professions, regulatory and licensing bodies, and organizational structures renders rapid adaptation to changing circumstances difficult. These realities suggest that one should not rush headlong toward ostensible solutions that leave some fundamental problems unaddressed. The first obligation to the health system and to nurses is to ensure that the domain of nursing practice matches their skill set. Only when nurses are allowed to withdraw from areas of non-nursing activity and redeploy their time and expertise toward what they should be doing will we know the true extent of the nursing shortage--if it exists at all. Achieving a proper division of labour that respects and maximizes professionals' competencies will not only make the health care system more effective and efficient. It will also create a better-motivated and contented workforce. Reference (1) Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002; 324: 819-823. |
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James F Munro, Clinical Senior Lecturer in Epidemiology Medical Care Research Unit, University of Sheffield, Sheffield S1 4DA, Alicia O'Cathain
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Dear Editor – Finlayson et al argue that problems in recruiting and retaining nurses may be hampering progress towards the “modernisation” of the NHS, (1) but it may also be the case that service changes under the banner of modernisation are contributing to the apparent nursing shortage. Critics have blamed new nurse-led services such as NHS Direct and walk-in centres in England, and NHS 24 in Scotland, for recruiting skilled nurses from areas such as intensive care and accident and emergency nursing (2). The impact of new services must always be assessed in terms of their impact on the supply of scarce resources as well as on the demand for care. In the case of NHS Direct the overall impact on the supply of nurses has probably been negligible, at approximately 0.5% of all qualified nurses (3). Although the service employs in excess of 1200 wte nurses, 20% of these have been recruited from outside the NHS, and 10% have an illness, injury or disability which may in any case have led them away from clinical nursing (3). In addition, the effects of new services on staff shortages may be complex since, for example, NHS Direct has also reduced the need for nurses in some other parts of the NHS. Thus, there may be opposite short and long term effects on the staffing “gap”. Finally, one might note that the new nurse-led services may encounter their own difficulties in staff retention. (4) One in six NHS Direct nurses are bored at work and one in five nurses find their job satisfaction lower than in their previous post. (3) 1. Mind the gap: the policy response to the NHS nursing shortage. Belinda Finlayson, Jennifer Dixon, Sandra Meadows, and George Blair. BMJ 2002; 325: 541-544. 2. Marsh B. Scandal of the stolen nurses. Daily Mail 10 January 2000 :5. 3. Impact of NHS Direct on other services: the characteristics and origins of its nurses. Morrell CJ, Munro J, O’Cathain A, Warren K, Nicholl J. Emerg Med J 2002;19:337–340. 4. Knowles E, O’Cathain A, Morrell J, Munro JF, Nicholl JP. NHS Direct and nurses - opportunity or monotony? International Journal of Nursing Studies 2002 (in press). |
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Penny Curtis, Senior Lecturer in Midwifery Research WICH Research Group, University of Sheffield, Sheffield. S3 7ND, Linda Ball and Mavis Kirkham
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The findings reported by Finlayson et al are indeed worrying for the NHS and the programme of modernisation to which the government is committed. Growing disenchantment with the conditions under which NHS staff groups are required to work, which Finlayson et al describe, is also evidenced in a study which examined the reasons why midwives cease to practice. The Why do Midwives Leave study , on which we reported earlier this year, was funded by the Royal College of Midwives and the Department of Trade and Industry in response to concerns about the chronic difficulties with retention in midwifery. The methods employed by Finlayson et al to explore staff morale, motivation and retention included the generation of focus group data. These involved staff currently employed in the NHS. By contrast, the Why do Midwives Leave? study elicited the experiences and perspectives of midwives who had recently ceased to practice – those who had left the workforce. Because midwives are required to notify their intention to practice every year, those who do not do so can be readily identified by the Nursing and Midwifery Council (formerly the United Kingdom Central Council for Nursing, Midwifery and Health Visiting [UKCC]). Thus we were able to contact recent leavers and explore with them, through individual interviews and a postal questionnaire survey, their reasons for leaving. Making the decision to leave midwifery was often a protracted and painful experience for individuals. The largest single group of leavers were those who had become dissatisfied with the organisation of midwifery care and with their role as midwives. However, when other reasons for leaving were given, factors such as family commitments, personal illness or maturation of pension rights had often tipped the scales that had been increasingly weighed down with a growing sense of dissatisfaction with various aspects of midwifery work. All of the factors identified as having important affects on morale and motivation by Finlayson et al are also identified in the WML study. Clinical midwives feel undervalued within the service and by their own managers in particular. They felt that they have little or no power to affect their work environment or to influence where, when or how they worked. Support was perceived to be ineffective and often not available within a work environment characterised by ever increasing workloads and rising levels of client dependency. There was worrying evidence of bullying and horizontal violence as colleagues struggled to cope with the increasing demands that were placed upon them. Perhaps surprisingly, a majority of leavers would consider returning to midwifery practice if the conditions were right for them. However, the complexity of the issues highlighted by midwives, and the intransigence of some of the problems that they experienced, mean that encouraging midwives to return is unlikely to be amenable to simple solutions. The modernisation of the NHS and improvements in service quality can only be brought about with a healthy and committed workforce, as the Government’s recent White Paper acknowledges . The voices of midwives who have, often reluctantly, left their profession, suggest that these will need to be accompanied by fundamental organisational and cultural changes. 1. Finlayson B, Dixon J, Meadows S, Blair G. Mind the gap: the extent of the nursing shortage. BMJ 2002; 325: 538-541 Finlayson B, Dixon J, Meadows S, Blair G. Mind the gap: the policy response to the NHS nursing shortage. BMJ 2002; 325: 541-544 2. Ball L, Curtis P, & Kirkham M, Why Do Midwives Leave? Royal College of Midwives London, 2002 3. Department of Health. A first class service: quality in the new NHS. London: Department of Health, 1998. |
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HEATHER M GAGE, Senior Lecturer Dept of Economics, University of Surrey, Guildford, Surrey, Rosemary Pope, Fiona Lake
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The nursing shortage described by Finlayson et al [1] is not a new phenomenon. It has been a recurrent problem over decades, but it is set to worsen. The proposed new expenditure on the NHS will have a profound, but as yet unknown, effect on the demand for nursing staff, such that serious shortages in the short run are likely to constrain planned capacity expansions. The authors conclude from their analysis of UKCC data that “recruitment… is less problematic than retention”. Our own analysis suggests that attrition from the nursing profession is not as severe as from teaching [2]. Using British Household Panel Survey data (a representative sample of the UK population), we traced all qualified nurses and teachers under the age of 60. We found that 42.6% of nurses, compared to 53.9% of teachers, had left their professions between 1991 and 1996. Roughly equal proportions were not working (14.5% vs. 15.1%). Of nurse profession leavers in other work, 50% were employed in other caring occupations, such as social or child care, whilst only 20% of leaving teachers remained employed in education. Comparing nurse leavers and stayers, leavers were significantly older and less likely to be doing two jobs. They reported less shift working, earned on average 7% less, and expressed more satisfaction with their jobs than those remaining in nursing. Some amount of wastage is to be expected from any profession and nurses seem to compare favourably with teachers. However, 33% of working nurses, compared to 13% of teachers, reported that they were not satisfied with their jobs. What keeps these nurses in nursing? Is it dedication to the profession, home ties, or lack of better opportunities? Deepening shortages in future years may generate higher rewards that mitigate nursing pay inequalities: teachers in the BHPS sample averaged 50% higher incomes than nurses. The concern is however, that we will continue to rely on nurses’ goodwill. References [1] Finlayson B, Dixon J, Meadow S, Blair G. Mind the gap: the extent of the NHS nursing shortage. BMJ 2002; 325: 538-541 [2] Gage H, Pope R, Lake F. Keeping nurses nursing: a quantitative analysis. Nursing Times 2001; 97 (7): 35-37 |
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Phillip J. Colquitt, Independent
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Editor, Given the UK situation[1], readers may find the following abstract of nursing crisis related story, from a national Australian television broadcast of October 8 2002 (last evening) interesting. It is taken directly from the free and full-text Australian Broadcasting Corporation(ABC) web site[2]. A full-text transcription of the segment is available free online[3]. ABSTRACT "Australia's Nursing Crisis" "A recent Government report predicts that by 2006 the health system nationwide will be short of 31,000 nurses. They are walking away from the job in droves, and even increasing the number of training places will not be enough to fill the gap as a first step, hospitals and health care providers are being urged to develop strategies to retain the nurses they already have, particularly young graduates who can quickly become disillusioned." END ABSTRACT.(Source.[2]) Are there any reliable figures showing how many of those who are "walking away from the job in droves" in Australia, are in fact flying away from the job in a 747, in the direction of a heavily populated, soon to be very cold island, which island has a Pound buying 2.7 dollars in Australia. Phillip J. Colquitt, Oct. 9, 2002. Refs: [1]Mind the gap: the policy response to the NHS nursing shortage Belinda Finlayson, Jennifer Dixon, Sandra Meadows, and George Blair. BMJ 2002; 325: 541-544. [2]7.30 Report.ABC Online.Accessed Oct.9,2002. http://abc.net.au/7.30/ [3]Australia's Nursing Crisis. ABC Online. Accessed Oct.9,2002. http://www.abc.net.au/7.30/s696450.htm |
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