Fears over nursing shortages are widely documented in the news, especially following Britain’s decision to leave the EU. Dr Bill Whitehead, Head of Department of Health Care Practice, explains the reasons behind the shortage and what can be done to tackle it.
Why is there a shortage of registered nurses? There is a straightforward answer to this. At local, regional, national and international level, there is an increasing demand for people’s health care, generating a demand for high quality nursing skills and knowledge, which has created increased job opportunities. When coupled with a limited supply of registered nurses this, inevitably, becomes a “shortage profession”.
To dispel one myth at the outset: the reason for this shortage is not that there are insufficient people wanting to be nurses. The statistics indicate that there is at least double the number of applications for each place offered on nursing courses nationwide. Since nursing became a degree level profession, the programme has been by far and away the most popular degree in terms of applications in the country.
At the University of Derby, we have seen applications running at over 10 applicants to each place and the reduction this year due to the changes in funding for the programmes has only reduced this over supply of applicants to around 8 to 1. The restriction in numbers entering the profession has been due to the number of places being offered nationally being lower than the number of jobs being available at the end of the courses.
There are not enough registered nurses to provide the care needed by the people of the UK. This is true in the National Health Service and other public sector organisations, as well as voluntary charitable organisations, private and independent health care sectors. The shortage of nurses is generally seen as a particular issue for large acute general hospitals. These large hospital trusts, both locally and nationally, do have large shortages; almost every general hospital nationally, currently has hundreds of registered nurse vacancies.
However, this shortage is also felt in community nursing, mental health nursing, learning disabilities nursing, child nursing and midwifery. It is a shortage in all other areas where registered nurses are needed such as private health care, nursing homes, privately owned NHS treatment centres, GP surgeries and prisons, to name just a few of the locations where the over 600,000 registered nurses are employed.
Why is there a shortage of nurses?
As with all ‘commodities’, the availability of health care is regulated by supply and demand. In the health economy, as in many other industries, the two are intertwined.
Worldwide, the demand for health care and, consequently, for registered nurses is increasing. This is led by increasing prosperity improving expectations of longer life and the health care to go with it; along with advances in public health, medical, pharmacological and healthcare science generating new therapeutic, medical and surgical treatments.
These ‘commodities’ were not in existence in the past but are now, understandably, desired by people wanting the best for their family and themselves. In the UK, we are fortunate to have a health care system dominated by the National Health Service which has been successful in redistributing health resources much more fairly than in some parts of the world.
The overall demand is increasing due to increasing expectations driven by scientific advancement and socio-economic improvement.
It would appear to be common sense that increasing numbers of people entering the UK from overseas would increase the demand for health care and that in a National Health Service, provided free at the point of use, there would be increased overall competition for health care.
However, this is balanced out by the fact that the vast majority of people migrating into the country are of working age and thus contribute to the economy and taxation system, which funds the bulk of health care, more than they are likely to require themselves in health care. In addition, due to the undersupply of nursing graduates, many UK employers have sought registered nurses from overseas to fill vacancies left unfilled by British registered nurses.
Therefore, without immigration, the shortage of nurses would be even more acute. This is nothing new, as many of previous generations of people moving to the UK have been actively recruited by employers to fill nursing vacancies for the last 60 years or more.
Consequently, immigration has a worst a neutral effect on the combination of supply and demand for health care in the UK and is certainly of less importance than the ageing population and increasing expectations of the population in general.
The overall longevity of the population is increasing. This is a desirable result of the improvements in prosperity and medical science and technology indicated above. However, along with increased age comes increased risk of illness and disability. As the population of older people increases, the need for their health and social care increases alongside it. The majority of this care is delivered by unwaged family and friends. A further large proportion of care is provided by employed carers who are qualified at a level not currently requiring professional registration.
However, due to the social and scientific advances suggested above, an increasing proportion of this care requires the level of skill and knowledge required of registered nurses in order to ensure the rightly increasing demand for high quality care provision.
Expansion of nursing roles
Nursing never was restricted to hospital ward based care of acutely ill patients. It has always included community district nursing, health visiting, school nursing, general practice nursing, occupational health nursing, residential care nursing, mental health nursing, learning disabilities nursing and child nursing, as well as a long list of specialist posts and managerial, research and education positions. This wide range of ability and employment opportunities is why nursing has always been such a large profession.
But as health care becomes more complex, the need for advanced nursing skills is increasing and, consequently, new roles such as advanced care practitioner are increasing alongside the increasing demand for existing roles which remain required. In some cases, these new advanced nursing roles are seen as substituting what were traditionally the medical profession’s responsibilities.
Nurses leaving the profession
There are large numbers of nurses leaving the profession every year. This is mainly due to decisions to change career, leaving the labour market altogether or retirement. These reasons are the same for any profession. However, in nursing the incentive to bring these decisions forward is often added to by the stresses of the job becoming too great and feeling that they are unable to provide the quality of care that they would ideally like to provide.
This anxiety is often linked to a lack of resources caused by the undersupply of registered nurses itself. In any line of work, if there are insufficient skilled people to provide the service then either there will be a reduced service or the overall quality will suffer. Consequently, the number of nurses leaving nursing early would be likely to be reduced, if the number of nurses joining the profession were increased.
There is no shortage of applicants to nursing schools around the country and certainly not to the University of Derby. Some commentators have indicated that although there are large numbers of applicants, many of them are not suitable for nursing. All nursing programmes do require applicants to provide good pre-university qualifications, to have experience as carers and to succeed at a face to face selection event including interview.
The University of Derby has been increasing its number of places on nursing programmes for the past few years and has not seen a decline in quality despite a significant rise in the quantity of graduates. There is no obvious reason why this will not continue to be the case both locally and nationally if the necessary numbers of applicants are accepted to a greater number of places, but it will need careful monitoring in order to ensure the quality of care delivered by graduates remains consistently high.
Therefore, it would appear that there are sufficient applicants to grow the number of student nurses and, subsequently, registered nurses if we choose to increase the number of places on nursing programmes.
All of the above indicates that the number of places on nursing courses needs to increase. The obvious question is “why haven’t we increased them already?” The University of Derby has increased the number of adult nursing students over the last few years. However, this has been entirely controlled by Health Education England (HEE) as the system up until this year has been that student fees have been paid centrally. This has been dependant on national priorities for spending as well as perceived workforce demand and consequently, has often lagged behind the actual demand.
In addition, the NHS has recently been setting higher minimum nurse staffing numbers in response to criticisms of quality linked to the quantity of nurses available to provide care. Therefore, what had previously been seen by employers as sufficient numbers became perceived shortages.
From September 2017, the Government has decided to change the system of funding to the Student Loan Company, rather than central HEE funding. This allows universities to provide as many places on nursing programmes as they can within fundamental structural restrictions. The restrictions are primarily ones of resources. As already indicated, suitable applicants for registered nursing programmes is unlikely to be an issue. Therefore, the educational resources become the limiting factor.
For nursing programmes these are primarily:
- the number of clinical placements available
- the number of nurse lecturers and clinical nurse educators available to facilitate learning and assess proficiency to join the nursing register
- classrooms, lecture theatres and clinical simulation resources in the university
What can we do about it?
Increase number of places
There is a need for more nurses and, therefore, we should increase the number of nurses. The limiting factors listed above are all surmountable and require the efforts of all involved to facilitate a way to provide the increased resources required in the short term in order to reap the rewards of having the quality skilled registered nurse workforce to meet the expanding demands for health care.
Locally, at least, we have sufficient applicants under the new system to be able to increase numbers on our existing high quality BSc (Hons) Nursing programmes for mental health and adult nursing. However, the full time degree route is not the only way to enter many professions and for some people with the required capacity this would be a very difficult option.
In order to provide fairer and increased access to nursing, a number of new routes to the same level of professional and academic qualification are being developed. In addition, existing programmes leading to a foundation degree, most recently as a “nursing associate”, often provide a route to enter the registered nurse course at a later stage.
These routes will provide a pathway to nursing for many people who otherwise would have found it very difficult to enter the profession. However, it should be noted that in order to be a registered nurse, at the end of whatever route is selected each registrant will be required to graduate with a degree and achieve the same professional standard and proficiencies that a registrant entering the profession through the full time degree route would.
There is a nursing shortage because of increased demand and shortage of registered nurse supply rather than a lack of applications for courses. As a society, we need to value the work undertaken by nurses, health professionals and carers to the extent that we both educate the required workforce and provide them with the resources required to fill the gap between supply and demand of quality health care.
The routes to registered nursing at the University of Derby can be found here.