Editorial

The nursing workforce: Achieving homeostasis

Roger Watson
School of Nursing and Midwifery, University of Sheffield, Sheffield, United Kingdom; Hong Kong Polytechnic University, Hong Kong

PP: 045 - 048

Article Text

Introduction

On a recent visit to Australia something unique occurred: for the first time, new graduate nurses were unable to find employment. The uniqueness of the event clearly surprised my colleagues and the news was reported in the broadsheets in serious, if not sensational, tones. Coming from the UK, the prospect of newly qualified nurses being unemployed is neither new nor news. While the disappointment must be terrible for the new nurse without a job and the waste of investment is manifest, we have become used to both severe shortages of nurses and then shortages of jobs for nurses as UK government and Department of Health workforce planning struggles to keep up with changes in supply and demand for nurses.

The nature of nursing job shortages or excess is both relative and obscure. Relative because the nurse to patient ratios or nurses per head of population we have in western developed countries – even in times of shortage – outstrip the ratios in developing countries, sometime by orders of magnitude (Buchan & Calman, 2004). Our periods during which nurses are unable to find employment often represent national economic downturns, local health service financial difficulties combined with ‘overproduction’ by schools of nursing. I will return to the issue of overproduction later. The nature of nursing shortage is also obscure, especially in the UK, as – apart from in critical care units – nurse to patient ratios are not fixed and what is considered unsafe one day soon becomes acceptable, if the cost of safety exceeds the budget.

What Else I Learned in Australia

Nurse education in Australia is funded directly by the state governments and not, as in England, by the health service (the National Health Service [NHS] in the UK, although my comments here refer only to the situation in England). Of course, health services and provision of hospital care differ greatly between Australia and the UK with the private sector playing a much greater role in Australia. In the UK, the private sector, while growing, is negligible and health and hospital provision in the UK is synonymous with the NHS. In England, as previously explained in these pages and elsewhere (Shields & Watson, 2007, 2008; Watson & Shields, 2009), nursing education is commissioned and funded by the NHS. This contrasts with other university education, including medicine, which is funded by the government bodies responsible for funding higher education in the four countries of the UK (e.g., the Higher Education Finding Council for England [HEFCE] in England). I envy my Australian counterparts in university schools of nursing and midwifery because I see nothing but negative consequences of the link between NHS funding and nursing education; the fact that we go from shortage to overproduction testifies to the fact that this link does not even work. However, my Australian colleagues warned me, the hospitals and health services in Australia are under no obligation to provide practice placements for nursing student experience and, as far as I understand it, resources change hands – often in the shape of university staff who spend their time in the clinical areas supporting students – because the hospitals do not feel an obligation towards the students. How much better it must be in the UK system where the NHS has an obligation towards the students whose education then commission … you would think.

Lessons from the UK

The late 1990s and the early 2000s were a ‘boom time’ for the UK nursing education industry. The UK was short of nurses for many reasons: we were not producing enough, they were leaving the profession early due to dissatisfaction and stress (Deary, Watson, & Hogston, 2003; Watson, Deary, Thompson, & Li, 2008; Watson et al., 2009) and the profession was ageing (Andrews, Watson, & Manthorpe, 2006; Watson, Manthorpe, & Andrews, 2003; Wray, Aspland, Gibson, Stimpson, & Watson, 2007a, 2007b, 2009). They were also leaving nursing programmes at a great rate with some schools of nursing reporting up to 50% attrition. The country was experiencing a period of relative economic stability (I write this at a time of severe economic depression) and the relatively new Labour government – but one facing an election – knew that few things were likely to be more popular with voters than stocking the NHS with a plentiful supply of newly qualified nurses. Little attention was given to the reasons nurses were leaving the NHS and, in true Stalinist fashion, one of the largest organisations in the world, the UK NHS with the UK Department of Health at the helm, went into overproduction mode with regard to nursing education. Like the Soviet tractor factories, production was high but quality was low and dissenters were, largely, silenced. The equivalent of the poor quality tractors rusting in the fields – those nurses leaving nursing education prematurely – were dealt with by universities being exhorted to reduce attrition and maintain attrition levels at below average, despite the obvious mathematical nonsense of this as the average would be determined by the levels of attrition, and so on. Nevertheless, UK universities with schools of nursing complied; it was good business (Watson, 2006). Soon, those of us engaged in nursing education were occupied admitting hundreds of nursing students to some schools. To accommodate this we were taking two intakes a year and then dividing the classes in two to deliver teaching to manageable class sizes—i.e., ones that could be crammed into our largest lecture theatres. In three years of engagement with this, I delivered the same lecture 12 times and this pattern was repeated by most colleagues.

Thus far I am not entirely sure how congruent this pattern is with Australia but it is fair to say that UK university schools of nursing never ‘had it so good’ in terms of income: student numbers were often the largest in any university, schools of nursing were major contributors to the income of universities and we could barely fill all the teaching posts we had available. The downside, as reported before, was the effect that this had on research, both directly as a result of the burdensome teaching loads and indirectly as a results of the lack of NHS funding for research. Some enlightened deans of nursing protected research activity by supporting research posts and providing such simple things as support staff for the nursing professoriate; most were not so enlightened. However, as with most ‘booms’ there ensued a ‘bust’ and this came in the shape of the first signs of economic downturn in the mid-2000s and the fact that the universities had a significant success to report: they had helped the NHS to fulfil its recruitment of newly qualified nurses. Surely some reward was in store or, at least, a period of stability where university schools of nursing could consolidate on their significant income and recruitment of staff to focus more on research and scholarly activity. The deluded amongst us were not deluded for long as NHS budgets for nursing education were cut having a direct effect on schools of nursing and, in the intervening years, significant redundancies have taken place amongst nursing academics and the survival of some schools is in doubt. Ironically, universities and their schools of nursing were now being punished for their success and, it seems, nobody saw this coming.

Diversity in Adversity

Of course, nursing schools are not alone in suffering financial hardship in these straitened times. Universities as a whole are suffering, and the message promulgated is one of diversification in pursuit of new sources of income. Whenever this call goes out in UK universities, attention turns to the international market. Internationalisation is nothing new to most universities in the UK and worldwide, and international students represent a lucrative market due, in the UK, to the significantly higher fees they are charged. In the UK, we are slightly hampered by this in terms of European Community students being charged at the same rate as home students, but there is increasing activity in the Far and Middle East to attract students. Frankly, some university departments and disciplines depend on this for their survival. Therefore, what about nursing?

Some nursing schools are successful at recruiting international students but few could be said to be surviving on this market. Mostly, it is in the taught postgraduate programmes and postgraduate research programmes that recruitment takes place and, by the nature of these programmes, recruitment is relatively low. For nursing schools in the UK the situation is compounded by the funding arrangements: the NHS funds local universities to produce nurses for local need and this short-term and short-sighted strategy (which also runs alongside the wholesale depletion of nurses from developing countries to stock the NHS) is not only the policy; it is enforced. I am not alone in meeting hostility, resistance and ‘what’s the point?’ questions in relation to my own international activities. This has been followed by ‘how does this activity benefit the local NHS?’, as if the NHS was my employer. I have even had my position as Editor-in-Chief of the largest academic nursing journal in the world questioned and discouraged by line managers. This is not just the expression of a poor understanding of what constitutes legitimate and prestigious academic activity; it is an expression of the mentality that has been instilled in those ‘managing’ nurse education in many UK universities.

The relevance to the present argument about the nursing workforce is that this mentality, and its manifestation in lack of support for research and activities outside the locality in which the nursing contracts are funded, is damaging nursing schools, making them less fit to compete within their universities for recognition and resources and, subsequently, weakening their ability to compete nationally and internationally. Nobody in the British government and the NHS sees this as a problem; expediently, we do not need so many nurses, therefore, schools of nursing can be left to wither on the academic vine. But what happens when we need more nurses, as will inevitably happen when the economy improves and the current cutbacks lead to nursing shortages? Furthermore, what will happen in the UK in 2013 when all nursing education moves to graduate level and we require research experienced, internationally aware colleagues to provide this higher level of education for the entire nursing student intake? Will we be ready? Will there be enough of us? I doubt it and also doubt that the NHS and the UK Department of Health have even considered this.

I started this editorial with reference to current developments in Australian nursing and it is appropriate to end there too. I sense a vibrant academic culture in nursing in Australia; you currently have all graduate entry to the profession; funding of nursing education is not parochial and you have substantial numbers of international students on your programmes. Treasure these things, do not lose them and do not panic if there are some unemployed new graduates; one day we’ll need them.

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