tag:theconversation.com,2011:/us/topics/nursing-819/articlesNursing – The Conversation2024-03-21T19:08:08Ztag:theconversation.com,2011:article/2262362024-03-21T19:08:08Z2024-03-21T19:08:08ZAged care workers have won a huge pay rise. What about the cleaners, cooks and admin staff who support them?<p>This month, the Fair Work Commission handed Australia’s aged care workforce an <a href="https://www.abc.net.au/news/2024-03-15/aged-care-workers-pay-rise-case-ends/103591208">historic pay rise</a>, with some groups’ wages set to increase by more than 28%. </p>
<p>The news was a welcome relief for much of the female-dominated workforce, who have faced <a href="https://theconversation.com/todays-aged-care-falls-well-short-of-how-wed-like-to-be-treated-but-there-is-another-way-177067">chronic staffing shortages and poor rates of pay</a> in recent years. </p>
<p>But not everyone working in the aged care industry was counted equally. </p>
<p>A whole host of workers essential to running aged-care facilities – such as cooks, cleaning staff and administrative assistants – are included in what’s called the <a href="https://www.agedcareguide.com.au/talking-aged-care/providers-indirect-and-direct-care-workers-how-stage-three-will-impact-you">indirect care workforce</a>. Many of them will get a raise of just 3%. </p>
<p>Australia now risks continuing to leave behind this hardworking and often overlooked group. </p>
<h2>Who gets more</h2>
<p>Most direct care workers on the Aged Care Award – such as nurses and care staff – will see a big pay increase from July this year, inclusive of <a href="https://www.fwc.gov.au/documents/decision-summaries/2024fwcfb150-summary.pdf">an interim 15% raise </a> awarded in 2023. </p>
<p>For example, workers on Level 3 of the award will see an overall wage increase of approximately 23% year over year, while workers on Level 5 (holding Certificate 4 in Aged Care and Disability) will see their pay go up by 28.5%.</p>
<p>Experienced nursing assistants on the new Aged Care Award will also receive a pay increase of 23%.</p>
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<h2>Who gets left behind</h2>
<p>Running an aged care facility is a multifaceted operation. Approximately <a href="https://helloleaders.com.au/article/aged-care-workers-could-see-28-pay-boost-indirect-care-workers-left-behind">100,000 residential aged care workers</a> are in “indirect care” roles, working across administrative and clerical services, food services, and laundry.</p>
<p>In its <a href="https://www.fwc.gov.au/documents/decision-summaries/2024fwcfb150-summary.pdf">decision</a>, the commission ruled that a “fundamental difference” between the work of direct and indirect care workers meant they did not deserve an equal pay increase.</p>
<p>The expert panel <a href="https://www.fwc.gov.au/documents/decision-summaries/2024fwcfb150-summary.pdf">said</a>: </p>
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<p>Without diminishing the importance of the work of indirect care for the proper functioning of residential aged care facilities, the above workers do not perform work equivalent in value to the direct care workers. </p>
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<p>For many workers in the areas of infection prevention and control, as well as some indirect workers in dementia wards, it awarded a pay increase of just 3%. </p>
<p>Other segments of the indirect care workforce received greater recognition. Laundry hands, cleaners and food service assistants who interact directly with residents saw this extra contact acknowledged, and won a raise of about 7%. </p>
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<img alt="A list of the aged care workforce, showing the direct care workforce is about 320,000 people and the indirect care workforce is about 100,000 people" src="https://images.theconversation.com/files/583350/original/file-20240321-16-1dhogn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/583350/original/file-20240321-16-1dhogn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/583350/original/file-20240321-16-1dhogn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/583350/original/file-20240321-16-1dhogn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/583350/original/file-20240321-16-1dhogn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/583350/original/file-20240321-16-1dhogn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/583350/original/file-20240321-16-1dhogn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<h2>A widening pay divide impacts quality of care</h2>
<p>At 3%, the lowest pay increase for this group is below the <a href="https://www.rba.gov.au/inflation-overview.html">current Australian inflation rate</a> of 4.1%. For them, increases in take-home pay will fail to meet the rising cost of living. 7% is only slightly higher, and just a fraction of the raises awarded in direct care. </p>
<p>Pay disparity in the treatment of indirect care workers could further entrench a serious equity divide, the impacts of which we may already be seeing. </p>
<p>At large provider BaptistCare NSW and ACT, employee turnover among direct care workers <a href="https://www.theweeklysource.com.au/sector-moves-people/direct-care-worker-turnover-drops-after-pay-rise-but-indirect-worker-turnover-remains-stubbornly-at-38">fell by about 6%</a> after last year’s interim pay rise, to 29.3%. But among their indirect care colleagues who did not receive the raise, turnover remained stubbornly high, above 38%.</p>
<p>High staff turnover poses a serious challenge to delivering quality aged care. </p>
<p>By influencing attitudes at work, the pay divide could also be exerting a profound influence on the quality of care delivered. </p>
<p>BaptistCare NSW & ACT has shared <a href="https://www.theweeklysource.com.au/sector-moves-people/direct-care-worker-turnover-drops-after-pay-rise-but-indirect-worker-turnover-remains-stubbornly-at-38">anecdotal reports</a> that indirect care staff have become less willing to assist their higher paid colleagues.</p>
<p>Australia cannot afford further negative influences on its aged care sector. </p>
<p>It hasn’t been long since the <a href="https://www.abc.net.au/news/2019-10-31/aged-care-royal-commission-report-finds-unsafe-industry/11658328">Royal Commission into Aged Care found</a> the “unkind and uncaring” system had failed to meet the needs of elderly people, and could even be neglecting them. </p>
<p>Pay rises for direct care workers are an important step in improving the quality of our aged care offering. But we could risk it all if we continue to leave part of its workforce behind.</p>
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Read more:
<a href="https://theconversation.com/who-will-look-after-us-in-our-final-years-a-pay-rise-alone-wont-solve-aged-care-workforce-shortages-225898">Who will look after us in our final years? A pay rise alone won't solve aged-care workforce shortages</a>
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<p class="fine-print"><em><span>Matthew Xerri is affiliated with the Centre for Work, Organisation, and Wellbeing at the Griffith Business School, Griffith University. </span></em></p>Most of the indirect care workforce will only see a pay rise between 3% and 7%.Matthew Xerri, Senior Lecturer in Human Resources, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2134992023-10-19T12:36:24Z2023-10-19T12:36:24ZNew treatment for postpartum depression offers hope, but the stigma attached to the condition still lingers<figure><img src="https://images.theconversation.com/files/552646/original/file-20231008-19-k1z29z.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C5991%2C3970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A lack of interest in the child is one of the signs of postpartum depression.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-sad-mother-holding-her-sleeping-baby-in-her-royalty-free-image/1489251307?phrase=postpartum+depression&adppopup=true">Drazen Zigic/iStock via Getty Images Plus</a></span></figcaption></figure><p>Postpartum depression can affect anyone, and it often sneaks in quietly, like a shadow in the corners of a new mother’s life. It presents significant challenges for around <a href="https://www.postpartumdepression.org/resources/statistics/">1 in 7 new mothers</a>, affecting their emotional well-being and overall quality of life and that of the newborn. </p>
<p>Many – <a href="https://www.marchofdimes.org/find-support/topics/postpartum/baby-blues-after-pregnancy#">if not most</a> – women experience the “baby blues,” or generalized feelings of sadness, worry, unhappiness and exhaustion, in the initial days after giving birth. In most cases, these mood changes <a href="https://www.nimh.nih.gov/health/publications/perinatal-depression">are resolved in the first two weeks after having a baby</a>. In contrast, the symptoms of postpartum depression endure for more extended periods, sometimes lingering <a href="https://www.nih.gov/news-events/nih-research-matters/postpartum-depression-may-last-years">for up to three years</a>. </p>
<p><a href="https://healthychildren.org/English/ages-stages/prenatal/delivery-beyond/Pages/understanding-motherhood-and-mood-baby-blues-and-beyond.aspx">The symptoms can also start</a> <a href="https://www.womenshealth.gov/mental-health/mental-health-conditions/postpartum-depression">during pregnancy</a>. Research shows that more than half of women who <a href="https://doi.org/10.1186/s12888-023-05030-1">experience depression symptoms during pregnancy</a> will develop postpartum depression too.</p>
<p>A much more <a href="https://www.ncbi.nlm.nih.gov/books/NBK544304/#">rare and severe psychiatric disorder</a> following delivery is called postpartum psychosis. Its onset is rapid and severe, with hallucinations, delusions and emotional distress, along with <a href="https://theconversation.com/rare-and-tragic-cases-of-postpartum-psychosis-are-bringing-renewed-attention-to-its-risks-and-the-need-for-greater-awareness-of-psychosis-after-childbirth-201282">bizarre and sometimes dangerous behaviors</a>. About 1 or 2 in 1,000 women experience postpartum psychosis after giving birth.</p>
<p>We are a <a href="https://www.linkedin.com/in/nicole-lynch-dnp-msn-cns-cne-rnc-ob-02088813/">clinical nurse specialist</a> and a <a href="http://www.linkedin.com/in/shannon-pickett-phd-lmhc-77022a42">licensed mental health counselor</a>, and together we have over 45 years of experience as educators and clinicians.</p>
<p>With proper awareness, education and intervention, perinatal mood disorders are <a href="https://ppdil.org/legislation/ppmd-awareness-month/">nearly 100% treatable</a>. We want women to realize that they are not alone, they are not to blame, and with help <a href="https://ppdil.org/what-helps/">they can be well again</a>. </p>
<h2>Crying, sadness and lack of bonding</h2>
<p>Following pregnancy, many women experience normal changes that can mimic symptoms of depression, such as sadness, worry and exhaustion. The transition to motherhood, particularly with a new baby in the home, can be overwhelming. However, it’s essential to distinguish between these common adjustments and <a href="https://www.marchofdimes.org/find-support/topics/postpartum/postpartum-depression#">more concerning signs of depression</a>.</p>
<p>If you or someone you know finds themselves experiencing any of the following symptoms persistently for over two weeks after giving birth, it’s crucial they reach out to their doctor, nurse or midwife. Here are some of the <a href="https://www.ncbi.nlm.nih.gov/books/NBK519070/#">most-reported symptoms</a> of postpartum depression:</p>
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<li><a href="https://doi.org/10.1177%2F1745506519844044">Lack of bonding and feeling disconnected</a> from the baby or experiencing a <a href="https://ym.care/rfx">lack of interest in them</a>.</li>
<li>Restlessness or moodiness and feeling unusually agitated or irritable.</li>
<li>Persistent feelings of sadness, hopelessness or being overwhelmed.</li>
<li>Experiencing physical symptoms such as persistent headaches, other body aches and pains or digestive issues that don’t resolve.</li>
<li>A profound lack of energy or motivation, making daily tasks feel daunting.</li>
<li>Significant changes in appetite and either eating too little or too much.</li>
<li>Disturbed sleep patterns, such as sleeping too much or too little, even when given the opportunity to rest.</li>
<li>Difficulty concentrating or making decisions, or experiencing memory problems.</li>
<li>Overwhelming feelings of guilt, worthlessness or inadequacy as a mother.</li>
<li>A notable decline in interest or pleasure in activities previously enjoyed.</li>
<li>Isolating from friends and family, avoiding social interactions.</li>
<li><a href="https://www.ncbi.nlm.nih.gov/books/NBK544304/">Thoughts of</a> <a href="https://theconversation.com/rare-and-tragic-cases-of-postpartum-psychosis-are-bringing-renewed-attention-to-its-risks-and-the-need-for-greater-awareness-of-psychosis-after-childbirth-201282">harming the baby or themselves</a>. These <a href="https://doi.org/10.1007/s10597-022-01002-z">should be taken extremely seriously</a> and <a href="https://doi.org/10.1155%2F2018%2F8262043">warrant immediate attention</a>.</li>
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<p><a href="https://doi.org/10.1089/jwh.2020.8862">Some risk factors</a> associated with higher likelihood of postpartum depression include life stress, <a href="https://doi.org/10.1177%2F2167702616644894">depression history</a>, maternal anxiety, lack of social support, infrequent exercise, unintended pregnancy and <a href="https://www.nimh.nih.gov/sites/default/files/documents/health/publications/perinatal-depression/perinatal-depression.pdf">intimate partner violence</a>.</p>
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<figcaption><span class="caption">Knowing the warning signs of postpartum depression could prevent a tragedy.</span></figcaption>
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<h2>Real-life examples</h2>
<p>People dealing with depression not only have to manage their symptoms but may also <a href="https://psycnet.apa.org/doi/10.1037/sah0000431">face the stigma</a> and discrimination that these conditions often bring. There is an expectation that new parents will be happy after delivery. Sadness, stigma, shame or guilt greatly affects a person’s willingness to seek help. Studies show that many people opt not to seek treatment to avoid being <a href="https://doi.org/10.1111/jmwh.13366">perceived as unfit parents by health care providers or family</a>. </p>
<p>As a nurse and a mom who has experienced postpartum depression, I (Nicole Lynch) frequently share my story with others. Years ago, another mom shared with me how helpful it was to hear that she wasn’t alone. Knowing that other women – dedicated parents who love their children – can feel this way and that <a href="https://www.postpartum.net/learn-more/depression/">things can get better gave her hope</a>.</p>
<p>Throughout my career, I (Shannon Pickett) have worked with several mothers and prospective parents who have struggled with postpartum depression. For instance, I worked with one woman for several years about her anxiety and her struggle to conceive. After years of trying, she finally became pregnant. Both she and her husband were overjoyed and could not wait to become parents. </p>
<p>The pregnancy went smoothly and there were no complications. She had never shown any signs of depression previously, but once the baby was born, that changed. My client had trouble bonding with the baby and did not want to hold or console her new son when he needed soothing.</p>
<p>Her husband would often step in to comfort the infant and would ask my client, “What is wrong with you?” It caused frustration within their marriage because the father felt as though he was doing the caregiving alone and that my client was withdrawn. She had planned to take a break from therapy for a bit after the baby was born, but her husband encouraged her to reach out to schedule an appointment. </p>
<p>I could tell right away that she was struggling with postpartum depression. She barely smiled, had difficulty engaging in and concentrating on our conversation and cried throughout most of the session. </p>
<p>We talked a lot about the guilt she felt over not wanting to be around her son or hold him, even though she had fought for so long to become a mother. After receiving a proper diagnosis and starting an antidepressant medication, my client was able to recover and bond with her son. The medication did take a few weeks to get into her system, so the results were not instant. Maintaining her sessions and using her support system were <a href="https://doi.org/10.2147/IJWH.S6938">important for her recovery as well</a>. </p>
<h2>Heightened risk</h2>
<p>While postpartum depression can affect anyone regardless of their socioeconomic status or their background, <a href="https://iris.who.int/bitstream/handle/10665/112828/9789241506809_eng.pdf?sequence=1">some women affected by social inequalities</a> have increased risk of many common postpartum mental disorders and their <a href="https://www.who.int/publications/i/item/9789240045989">adverse consequences</a>. </p>
<p>One study found that new mothers with low incomes, those who had not earned a college degree, were unmarried or were unemployed were 11 times more likely than women with no risk factors to have <a href="https://doi.org/10.1016/j.whi.2009.11.003">clinically elevated depression scores three months after having a baby</a>.</p>
<h2>Inadequate support</h2>
<p>The Centers for Disease Control and Prevention estimates that <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6919a2.htm">about 20% of pregnant women were not asked about depression</a> during a prenatal visit, and more than half of women with postpartum depression remain untreated for their symptoms. </p>
<p>What’s worse, there is a <a href="https://iris.who.int/bitstream/handle/10665/112828/9789241506809_eng.pdf">lack of access to mental health services</a> for women after delivery. Many promising treatments are underexplored, especially in scientific studies. While more people are talking about postpartum depression, there is <a href="https://doi.org/10.1111/jmwh.13366">still stigma around seeking help</a>. </p>
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<figcaption><span class="caption">A new oral medication may begin to relieve postpartum depression within three days.</span></figcaption>
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<h2>A new medication offers hope</h2>
<p>It’s vital to remember that postpartum depression is a treatable condition. Seeking help from health care professionals is a courageous and necessary step. </p>
<p>In August 2023, the Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-oral-treatment-postpartum-depression">approved the first oral medication</a>, Zurzuvae, <a href="https://www.youtube.com/watch?v=9085YWhyUTU">specifically intended to treat severe depression after childbirth</a>. It holds promise for addressing the complex array of symptoms associated with postpartum depression and offers newfound hope for affected mothers and their families. </p>
<p>If you are experiencing symptoms of postpartum depression, consider <a href="https://www.psychologytoday.com/us/therapists">finding a therapist</a> in your community for either telehealth or in-person sessions.</p>
<p>There are also <a href="https://ppdil.org/">postpartum support groups</a> that meet in person and online.</p>
<p>Supportive therapies, including counseling, medication and lifestyle adjustments, can significantly alleviate symptoms and improve overall well-being. Early intervention is key to a faster and more complete recovery, ensuring that mothers can enjoy the precious moments with their baby and find fulfillment in motherhood.</p><img src="https://counter.theconversation.com/content/213499/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lynch is a volunteer with the Post Partum Depression Alliance of Illinois <a href="https://ppdil.org/">https://ppdil.org/</a>. She serves as a Visiting Professor at Purdue Global.</span></em></p><p class="fine-print"><em><span>Shannon Pickett serves as University Faculty at Purdue Global.</span></em></p>Half a million new mothers in the US suffer from postpartum depression every year, yet a lack of awareness and stigma toward the condition keep many from getting the help they need.Nicole Lynch, Clinical Nurse Specialist and Visiting Professor of Nursing, Purdue UniversityShannon Pickett, Professor of Psychology and Licensed Mental Health Counselor, Purdue UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2123592023-08-29T20:13:06Z2023-08-29T20:13:06ZPharmacists should be able to work with GPs to prescribe medicines for long-term conditions<p>A national <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/unleashing-the-potential-for-our-health-workforce-review-appointment">review</a> of primary care workforce regulations is investigating ways to increase Australians’ access to quality health care.</p>
<p>The review is considering how health-care workers can use more of their skills and training, to work to their full scope of practice. This includes exploring who should be allowed to prescribe medications. </p>
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<p>Independent pharmacist prescribing is increasing around the world, and now trials are starting in most Australian states. </p>
<p>The review should focus on expanding pharmacists prescribing for stable conditions and long-term medications, under the direction of a GP.</p>
<h2>What’s the problem?</h2>
<p>It often seems like health workers are at odds, but there’s one thing the professional bodies for <a href="https://www.racp.edu.au/news-and-events/media-releases/racp-welcomes-report-from-medicare-taskforce-and-the-focus-on-multidisciplinary-care-but-patients-need-more-access-to-specialist-care">doctors</a>, <a href="https://www.apna.asn.au/about/media/budget-lays-the-groundwork-for-structural-change-in-health-care">nurses</a>, and <a href="https://ahpa.com.au/news-events/media-release-multidisciplinary-teams-the-key-to-unlocking-access-to-primary-care/">allied health workers</a> all seem to agree on: we need more team-based care. Governments agree too.</p>
<p>As rates of complex chronic disease rise, it’s no longer possible for one clinician to provide all the care, advice and support many patients need. </p>
<p>There is good <a href="https://grattan.edu.au/wp-content/uploads/2022/12/A-new-Medicare-strengthening-general-practice-Grattan-Report.pdf">evidence</a> that a team of different kinds of health professionals working together can improve access to and quality of care, and reduce costs. </p>
<p>But Australia lags other countries when it comes to letting primary care professionals use all their skills. Partly as a result, Australia ranks behind most wealthy nations in the <a href="https://pubmed.ncbi.nlm.nih.gov/36134523/">share</a> of GPs who say they delegate aspects of care to other workers. </p>
<p>That’s one reason for rushed appointments and long wait times, with nearly <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">one-quarter</a> of Australians saying they wait too long to see a GP, and almost one-third not getting to see their preferred GP. </p>
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Read more:
<a href="https://theconversation.com/how-do-you-fix-general-practice-more-gps-wont-be-enough-heres-what-to-do-195447">How do you fix general practice? More GPs won't be enough. Here's what to do</a>
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<p>There are lots of things holding teamwork back. They include workforce shortages in some parts of Australia, cultural barriers, inadequate IT systems, a fee-for-service funding model, and clinics getting too little support to change how they work. </p>
<p>But the rules about who can do what, and who gets paid for doing what, are a big part of the problem. That will be the focus of this review. </p>
<h2>Scope to share prescribing</h2>
<p>The Pharmaceutical Benefits Scheme funds <a href="https://www.pbs.gov.au/info/statistics/expenditure-prescriptions/pbs-expenditure-and-prescriptions">215 million</a> prescriptions each year. In the five years to 2021–22, that number rose by an average of 3.3 million prescriptions each year. </p>
<p>Those prescriptions can be written by authorised practitioners, such as doctors, dentists and optometrists, as well as nurse practitioners and midwife practitioners, who have post-graduate degrees. </p>
<p>Trials are underway to share this growing workload with pharmacists. This recognises pharmacists’ expertise in medicines, and their availability on a walk-in basis in most communities around Australia, including those with long waits for GP care. </p>
<p>It also reflects support from <a href="https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/bcp.13624">pharmacists</a> and <a href="https://chf.org.au/sites/default/files/what_australias_health_panel_said_about_pharmacy_prescription_.pdf">patients</a> for a prescribing role. </p>
<p>Victoria’s 12-month <a href="https://www.health.vic.gov.au/primary-care/victorian-community-pharmacist-statewide-pilot">pilot</a> is set to begin in October, and will allow pharmacists to prescribe repeat scripts for oral contraceptive pills, as well as treatments for some mild skin conditions and urinary tract infections (UTIs). </p>
<p>A similar <a href="https://www.nsw.gov.au/media-releases/statewide-pharmacy-prescribing-trial-to-begin">trial</a> is under way in New South Wales. </p>
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Read more:
<a href="https://theconversation.com/should-pharmacists-be-able-to-prescribe-common-medicines-like-antibiotics-for-utis-we-asked-5-experts-195277">Should pharmacists be able to prescribe common medicines like antibiotics for UTIs? We asked 5 experts</a>
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<p>Queensland, which already allows pharmacists to prescribe medications for UTIs, will begin a new <a href="https://statements.qld.gov.au/statements/96318">trial</a> later this year, allowing pharmacists to prescribe for a broader range of common health conditions. </p>
<p>Just a few weeks ago, Western Australia <a href="https://www.wa.gov.au/government/media-statements/Cook-Labor-Government/Pharmacy-option-for-UTI-diagnosis-for-Western-Australian-women-20230804">introduced</a> pharmacy prescribing for UTIs.</p>
<p>It’s new here, but in many other countries pharmacist prescribing is well established. Models vary, but pharmacists can write prescriptions in countries including Canada, New Zealand, the United States and the United Kingdom. </p>
<p>In a growing number of countries, pharmacists can prescribe independently. For example, in England <a href="https://www.england.nhs.uk/primary-care/pharmacy/pharmacy-integration-fund/independent-prescribing/">all</a> newly qualified pharmacists will soon be able to do so. </p>
<p>An approach that has been around for longer overseas but that isn’t part of trials here, is pharmacists prescribing under a clinical management plan agreed with a patient’s GP.</p>
<p>Under this model, people with stable, long-term conditions that are being successfully managed with medication can get prescriptions renewed by their pharmacist, rather than having to return to the GP. </p>
<p>The evidence shows this type of prescribing can be just as <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011227.pub2/epdf/full">effective</a> as prescribing by doctors. </p>
<h2>What approach should Australia take?</h2>
<p>The Australian review is an opportunity to follow the evidence and catch up with other countries. If expanding prescribing rights is done carefully, it will improve access to care and reduce costs, without compromising the quality and safety of care. </p>
<p>But if there are too many prescribers working independently, it could increase fragmentation of care in a system that is already disjointed and hard to navigate. This has been one <a href="https://www.racgp.org.au/gp-news/media-releases/2023-media-releases/march-2023/it-just-gets-worse-and-worse-more-concerning-detai">criticism</a> of recent Australian pharmacy prescribing trials, all of which have some component of independent prescribing. </p>
<p>By working in partnership with GPs, pharmacist prescribing could go beyond the narrow range of medicines and conditions covered in independent prescribing schemes. It would complement <a href="https://grattan.edu.au/wp-content/uploads/2018/05/208-2016-09-23-grattan-institute-submission.pdf">effective</a> pharmacy services that review medications and advise patients about them.</p>
<p>That’s why the review should focus on collaborative prescribing for stable, chronic conditions. This will help more patients, while keeping GPs at the heart of the primary care team, making sure that the pieces fit together. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-evidence-shows-pharmacist-prescribing-is-nothing-to-fear-127497">The evidence shows pharmacist prescribing is nothing to fear</a>
</strong>
</em>
</p>
<hr>
<p>As in other countries, additional training will be needed for pharmacist prescribers, and a range of implementation <a href="https://academic.oup.com/ijpp/article/27/6/479/6099842">issues</a> need to be considered. This includes ensuring:</p>
<ul>
<li>pharmacists have sufficient training and skills</li>
<li>efficient systems are in place for sharing clinical information and working with GPs</li>
<li>both the pharmacists and the GPs they work with are paid appropriately. </li>
</ul>
<p>Getting to the future of team-based care that all the major health professional groups espouse will require compromise. Pharmacy prescribing is already here, and it’s likely to go further. To get the best results for patients, community pharmacists should welcome leadership from GPs, while GPs should support pharmacist prescribing.</p><img src="https://counter.theconversation.com/content/212359/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon's employer, Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p><p class="fine-print"><em><span>Aaron Yin is currently on secondment to the Grattan Institute from the Victorian Department of Health.
Grattan Institute, has been supported in its work by government, corporates, and philanthropic gifts. A full list of supporting organisations is published at <a href="http://www.grattan.edu.au">www.grattan.edu.au</a>.</span></em></p>A new review of Australian health care workers’ scope of practice should focus on expanding pharmacists prescribing for stable conditions and long-term medications, under the direction of a GP.Peter Breadon, Program Director, Health and Aged Care, Grattan InstituteAaron Yin, Associate, Health & Aged Care Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2113982023-08-22T12:25:59Z2023-08-22T12:25:59ZMost US nursing homes are understaffed, potentially compromising health care for more than a million elderly residents<figure><img src="https://images.theconversation.com/files/542411/original/file-20230811-21-ml692x.jpg?ixlib=rb-1.1.0&rect=0%2C23%2C7959%2C5266&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nursing homes in poorer neighborhoods tend to have more critical staffing issues.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-male-care-worker-helping-woman-off-bed-with-royalty-free-image/1433524154?phrase=nursing+home&adppopup=true">10'000 Hours/Digital Vision via Getty Images</a></span></figcaption></figure><p><em>More than 80% of U.S. nursing homes <a href="https://thehill.com/changing-america/well-being/longevity/3809450-more-than-8-in-10-nursing-homes-face-staffing-shortages-survey/#:%7E">reported staffing shortages</a> in early 2023. SciLine interviewed <a href="https://nursing.nyu.edu/directory/faculty/jasmine-travers">Dr. Jasmine Travers</a>, a gerontological nurse practitioner and assistant professor of nursing at New York University Rory Meyers College of Nursing, and asked her how the shortage affects health care for nursing home residents, if nursing homes in poorer neighborhoods have been hit harder by the shortages, and what can be done to fix the problem.</em></p>
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<iframe src="https://player.vimeo.com/video/853130474" width="500" height="281" frameborder="0" webkitallowfullscreen="" mozallowfullscreen="" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr. Jasmine Travers discussed the impact when nursing homes are short-staffed.</span></figcaption>
</figure>
<p><em>Below are some highlights from the discussion. Answers have been edited for brevity and clarity.</em></p>
<p><strong>Who lives in nursing homes in the United States?</strong></p>
<p><strong>Jasmine Travers:</strong> There are 15,000 nursing homes with approximately <a href="https://oig.hhs.gov/reports-and-publications/featured-topics/nursing-homes/">1.2 million residents</a>. That population can range in age, although most commonly it’s those 65 years of age or older.</p>
<p><strong>What is the current state of nursing home staffing?</strong></p>
<p><strong>Jasmine Travers:</strong> In 2001, the Centers for Medicare & Medicaid Services proposed minimum staffing standards. They indicated that total nursing hours should be <a href="https://doi.org/10.1177/1178632920934785">4.1 hours per resident per day</a>. And that’s including the registered nurse, the licensed practical nurse and the certified nursing assistants. Only 25% of nursing homes were found <a href="https://doi.org/10.1111/jgs.17678">to be meeting those total nursing hours</a> in 2019.</p>
<p><strong>How did the COVID-19 pandemic affect nursing home occupancy and staffing?</strong></p>
<p><strong>Jasmine Travers:</strong> Occupancy levels hovered at about 80% prior to the pandemic. During the pandemic, occupancy went down to a low of 67%. By the end of 2022, those levels <a href="https://www.statista.com/statistics/1223881/occupancy-rate-of-certified-nursing-facilities-in-the-united-states/">had gone up to 72%</a>. </p>
<p>Lower occupancy levels can be a significant issue. Higher occupancy brings in more revenue to the nursing homes. With lower occupancy and less revenue coming in, then that’s a decrease in financial support that the nursing home needs to run their day-to-day activities.</p>
<p><strong>How does nursing home staffing affect the quality of care and health outcomes for residents?</strong></p>
<p><strong>Jasmine Travers:</strong> A number of studies show that when staffing is low, <a href="https://doi.org/10.1177/1178632920934785">emergency hospitalization visits</a> increase. Some of these visits could have been addressed by care provided in the nursing home setting. We also see increased instances of <a href="https://doi.org/10.1016/j.jamda.2004.12.003">pressure ulcers</a>, <a href="https://doi.org/10.1093/geronb/55.5.S278">urinary tract infections</a>, <a href="http://dx.doi.org/10.14283/jnhrs.2020.24">falls</a> and <a href="https://doi.org/10.1080/08959420.2011.532011">deficiency citations</a> – issued when a nursing home does not <a href="https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter08-10.pdf">meet a certification minimum standard</a>. </p>
<p>When nursing homes are understaffed, that means there might not be a sufficient number of certified nursing assistants to, for example, answer call bells. That might translate to residents sitting in their beds needing help for longer periods of time. </p>
<p>In those instances, if a person doesn’t have someone to get them out of bed, sometimes they might try to get up themselves. And when they do that, they could be at risk of falling. Or if they stay in bed and they’re soiled, they’re at increased risk for urinary tract infections or pressure ulcers. </p>
<p><strong>What can be done to alleviate nursing home staffing challenges?</strong></p>
<p><strong>Jasmine Travers:</strong> Areas that are socioeconomically deprived or that lack good transportation, housing and schools are less <a href="https://doi.org/10.1111/jgs.17990">desirable places to work</a>. </p>
<p>Just recently, the Centers for Medicare & Medicaid Services released an announcement that they are going to allow for those in pediatric specialties to receive loan reimbursements and loan forgiveness <a href="https://www.hhs.gov/about/news/2023/06/09/hhs-announces-new-15-million-loan-repayment-program-strengthen-pediatric-health-care-workforce.html">for working in underserved areas</a>. A similar program for those working in nursing homes would likely increase staffing. </p>
<p>I’d also like to see improved wages and benefits and more investment in retention efforts to keep the people who are already working in nursing homes working there.</p>
<p>One of the biggest issues when it comes to staffing is turnover. People will stay when the work environment is changed. And when people stay longer, they know their residents more. That consistency translates to better quality of care.</p>
<p>Watch the <em><a href="https://www.sciline.org/health-medicine/nursing-home-staffing/">full interview</a></em> to hear more.</p>
<p><em><a href="https://www.sciline.org/">SciLine</a> is a free service based at the nonprofit American Association for the Advancement of Science that helps journalists include scientific evidence and experts in their news stories.</em></p><img src="https://counter.theconversation.com/content/211398/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jasmine Travers receives funding from Robert Wood Foundation and the National Institutes of Health. </span></em></p>Reduced staffing means nursing home residents make more unnecessary trips to the hospital.Jasmine Travers, Assistant Professor of Nursing, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1996332023-02-24T04:19:31Z2023-02-24T04:19:31ZNHS recovery plan: why an extra £2.6 billion is not enough without more staff<figure><img src="https://images.theconversation.com/files/511633/original/file-20230222-18-5b2d4y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sheffield-uk-57-support-your-nhs-2003568701">Matthew Troke/Shutterstock</a></span></figcaption></figure><p>The UK government has announced an extra £1 billion of funding to support 800 new ambulances, 100 specialist mental health vehicles and 5,000 more sustainable hospital beds. This sum has been ringfenced for 2023-24 to provide extra capacity and support for staff in the urgent and emergency services. Rishi Sunak’s plan also includes £1.6 billion, to be provided up to 2025, for adult social care, and £150 million for building 150 new facilities to support mental health care. </p>
<hr>
<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/nhs-recovery-plan-why-an-extra-2-6-billion-is-not-enough-without-more-staff-199633&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p><em>You can listen to more articles from The Conversation, narrated by Noa, <a href="https://theconversation.com/us/topics/audio-narrated-99682">here</a>.</em></p>
<hr>
<p>This <a href="https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf">two-year plan</a> comes in response to emergency healthcare in Britain being labelled a “national emergency”. A recent <a href="https://committees.parliament.uk/publications/33569/documents/183655/default/">parliamentary report</a> investigating access to <a href="https://theconversation.com/why-ambulance-workers-in-england-and-wales-are-going-on-strike-196434">emergency services</a> has highlighted the lack of alternatives for emergency 999 calls and broken models of primary and community care.</p>
<p>Recent statistics show that in January 2023, on average <a href="https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2023/02/Statistical-commentary-January-2023-cftre1.pdf">72%</a> of patients attending A&E were either admitted, transferred or discharged within four hours. This represents a significant drop from the 95% standard, which was last met in July 2015. The <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-staff-strikes-facts-and-figures-on-the-uk-ambulance-workforce#number-of-ambulance-staff">average waiting time</a> for <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-response-times#:%7E:text=Category%202%20ambulance%20calls%20are,from%20sepsis%20or%20major%20burns.">category 2 ambulance calls</a>, meanwhile, is over an hour and a half (93 minutes), against a target of 18 minutes. </p>
<p>The government’s plan seeks to <a href="https://www.england.nhs.uk/2023/01/major-plan-to-recover-urgent-and-emergency-care-services/">improve</a> the four-hour A&E wait performance, bringing it up to 76% of patients by March 2024. It aims to achieve ambulance waiting times of 30 minutes, on average, for category 2 situations over the next year. And it prioritises finding healthcare solutions in the community to free up hospital beds.</p>
<figure class="align-center ">
<img alt="An ambulance outside an A&E department." src="https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511640/original/file-20230222-20-ucxxfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One in four paramedics say they would leave the profession if they could.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-june-17th-2020-ambulance-1758285437">Chris Dorney/Shutterstock</a></span>
</figcaption>
</figure>
<p>Research has long shown, though, that the <a href="https://www.nuffieldtrust.org.uk/news-item/crisis-of-health-service-resilience-is-years-in-the-making?utm_source=Nuffield+Trust+weekly+newsletter&utm_campaign=71fb09b732-EMAIL_CAMPAIGN_2020_03_19_04_06_COPY_01&utm_medium=email&utm_term=0_39741ccd5c-71fb09b732-92252867">problems</a> facing the NHS – the extent to which it is “broken” – are far greater. Issues around safety, staffing levels and quality of service over the last months have seen the service compared to a <a href="https://theconversation.com/its-like-being-in-a-warzone-aande-nurses-open-up-about-the-emotional-cost-of-working-on-the-nhs-frontline-194197">“war zone”</a>. An extra £2.6 billion in funding will not be enough to fix the problem.</p>
<h2>Workforce in crisis</h2>
<p>The <a href="https://www.bbc.co.uk/news/health-64190440">latest figures</a> show that <a href="https://theconversation.com/gp-numbers-continue-to-fall-but-the-uk-isnt-unique-in-losing-family-doctors-198699">the UK</a> has fewer <a href="https://www.bbc.co.uk/news/health-61986441">GPs</a> and <a href="https://nhsproviders.org/resources/briefings/community-network-the-staffing-challenges-facing-community-health-services-and-how-we-can-address-them">nurses</a> than most of its OECD counterparts. </p>
<p>Across the NHS, between July and September 2022, there were about 133,000 <a href="https://www.bbc.co.uk/news/uk-64185316">vacancies</a> for full-time staff. An estimated average of <a href="https://www.nuffieldtrust.org.uk/resource/nursing-strikes-facts-and-figures-on-uk-nursing-staff">17,000</a> nursing posts remain unfilled on any given day. In the year to June 2022, one in nine nurses left active service in England; the <a href="https://www.nuffieldtrust.org.uk/news-item/our-urgent-care-system-needs-long-term-rehabilitation-to-meet-patients-needs?utm_source=Nuffield+Trust+weekly+newsletter&utm_campaign=71fb09b732-EMAIL_CAMPAIGN_2020_03_19_04_06_COPY_01&utm_medium=email&utm_term=0_39741ccd5c-71fb09b732-92252867">turnover rate</a> hit 11.5%. </p>
<p>These nursing shortages are resulting in <a href="https://theconversation.com/nhs-nurses-pressures-taking-toll-on-compassion-and-kindness-our-new-study-shows-84315">massive pressure</a> on the frontline staff. A January 2023 article in the Times quoted the director of the Royal College of Nursing, Patricia Marquis, <a href="https://www.thetimes.co.uk/article/nhs-waiting-times-ambulances-heart-attack-stroke-mn50k7n8z">as saying</a> that what she called “corridor care” now appears to be commonplace: </p>
<blockquote>
<p>Some nurses are being booked to work in hospital corridors, others are being asked to buy Ikea hooks so intravenous drips can be attached to the corridor wall, and some patients are having cardiac arrests because of mistakes made using cumbersome oxygen cylinders to treat them.</p>
</blockquote>
<p>Among paramedics, more are now <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-staff-strikes-facts-and-figures-on-the-uk-ambulance-workforce#number-of-ambulance-staff">leaving</a> than are joining, with over one in four saying they would leave if they could. In the <a href="https://nhsproviders.org/media/693328/otdb-nhs-staff-survey-results-2021-final.pdf">2021 NHS Staff Survey</a>, only 20% of ambulance staff said there were enough staff in their organisation for them to do their job properly, compared with 30% in the 2019 survey.</p>
<p>Ambulance staff sickness and absences rates are among the <a href="https://bmjopen.bmj.com/content/11/9/e053885">highest</a> within the NHS. They have <a href="https://www.health.org.uk/publications/long-reads/why-have-ambulance-waiting-times-been-getting-worse">increased</a> from 5% in March 2019 to 9% in March 2022. </p>
<p>And in social care, the numbers are no better. Almost half a million adults were <a href="https://www.bbc.co.uk/news/uk-61413697">waiting</a> for council care services in England in the latter half of 2022, amid a record <a href="https://www.bbc.co.uk/news/uk-63177547">165,000 unfilled care jobs</a>. </p>
<p>For the government’s plan to work, it must increase the size and flexibility of the NHS workforce to bring any meaningful improvement in A&E and ambulance waiting times. This means <a href="https://www.nuffieldtrust.org.uk/news-item/our-urgent-care-system-needs-long-term-rehabilitation-to-meet-patients-needs?utm_source=Nuffield+Trust+weekly+newsletter&utm_campaign=71fb09b732-EMAIL_CAMPAIGN_2020_03_19_04_06_COPY_01&utm_medium=email&utm_term=0_39741ccd5c-71fb09b732-92252867">supporting</a>, protecting and retaining staff. However, it remains unclear how the government’s plan will address the acute staff shortages alone. </p>
<h2>Wider organisational crisis</h2>
<p>Beyond the staffing crisis, the NHS faces other critical systemic issues. The pandemic <a href="https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20210215%20GP%20access%20during%20COVID19%20report%20final_0.pdf">has exacerbated</a> problems in accessing GP services, which has seen <a href="https://www.kingsfund.org.uk/publications/solving-issue-gp-access-2019">more patients</a> attending A&E and calling for ambulances – thereby diminishing these services’ capacity to deal with more serious calls. </p>
<p>Further, there is considerable <a href="https://www.kingsfund.org.uk/projects/quality-cold-climate/reducing-variations">variation</a> in how different trusts deliver healthcare, as well as a <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226835/procurement_development_programme_for_NHS.pdf">lack of standard procedures</a> for how they purchase the products, supplies, equipment and services required to do so.
This both increases costs and reduces productivity. The ten ambulance trusts in England, for example, have <a href="https://www.england.nhs.uk/wp-content/uploads/2019/09/Operational_productivity_and_performance_NHS_Ambulance_Trusts_final.pdf">been shown</a> to be using 32 types of double-crewed ambulances, and no standard list of what they are to carry on board. </p>
<p>Elsewhere, across the ambulance trusts, <a href="https://www.ncbi.nlm.nih.gov/books/NBK506843/">non-conveyance rates</a> (when a 999 call does not result in a patient being taken to a healthcare facility) vary hugely, <a href="https://aace.org.uk/wp-content/uploads/2018/06/VAN-HSDR-report-2018.pdf">between 40% and 68%</a>. This can have significant consequences for patient safety and patient choice, not to mention the cost of additional journeys to A&E and <a href="https://dspace.stir.ac.uk/bitstream/1893/11298/1/Keith%20Colver_Treat%20and%20Refer_%20MPhil%20Thesis_FINAL.pdf">fears of litigation</a> brought against staff by members of the public if adverse events occur.</p>
<p>Poor working conditions are adversely affecting staff morale. Ambulance staff report <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-staff-strikes-facts-and-figures-on-the-uk-ambulance-workforce#number-of-ambulance-staff">frustration</a> at their inability to respond to 999 calls – and <a href="https://www.tandfonline.com/doi/abs/10.1080/09540962.2021.1899613?journalCode=rpmm20">serve patients effectively</a> – due to wider NHS and A&E pressures, over which they have little control. Staff are increasingly demoralised, staff sickness absences are growing, and support for their wellbeing <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08729-1#citeas">varies significantly</a> across trusts. </p>
<p>With <a href="https://www.theguardian.com/society/2023/jan/20/nhs-leaders-unite-union-ambulance-strikes-planned">reports</a> of more planned ambulance strikes, things are likely to get worse unless the pay dispute is resolved. However, the timing of the introduction of the <a href="https://bills.parliament.uk/bills/3350">transport strikes (minimum service levels) bill</a> creates doubts about the government’s willingness to negotiate. Some political commentators have <a href="https://www.theguardian.com/commentisfree/2023/jan/15/if-rishi-sunak-doesnt-drop-the-macho-act-were-in-for-a-spring-of-continuing-misery">suggested</a> it could lead to a “spring of continuing misery”. </p>
<p>Current strikes within healthcare have been agreed with minimum staffing levels for “life and limb cover” assured. It is, however, interesting to consider that minimum levels of service are not protected under any law on non-strike days. </p>
<h2>No easy fixes</h2>
<p>The problems the NHS faces have been years in the making. They stem from poor decision-making and a lack of political consensus between the two main parties, as well as what some critics have termed an <a href="https://www.spectator.co.uk/article/how-to-fix-the-nhs/">emotional attachment</a> on the part of some politicians to a free NHS. </p>
<p>Most crucially, the service has faced critical <a href="https://www.theguardian.com/commentisfree/2023/jan/15/lest-we-forget-our-nhs-crisis-is-the-deadly-legacy-of-george-osbornes-austerity">underinvestment</a>.
Recent analysis <a href="https://www.kingsfund.org.uk/projects/positions/nhs-funding">suggests</a> that while the recent budget increases are necessary, systemic challenges (particularly around workforce pressures) are likely to continue, including uncertainty about post-pandemic recovery.</p>
<p>This underinvestment has led to serious infrastructural issues. Hospital roofs <a href="https://www.newcivilengineer.com/latest/nhs-trusts-need-hundreds-of-millions-to-stop-hospitals-ceilings-collapsing-10-10-2022/">are collapsing</a>, with NHS England <a href="https://www.theguardian.com/society/2022/sep/28/nhs-england-hospital-roofs-in-danger-of-collapsing-will-not-be-fixed-until-2035">reportedly</a> admitting that “30 buildings at 20 different hospitals run by 18 individual NHS trusts” have at least one roof built with a type of cheap concrete that has been labelled “a ticking timebomb”. There have also been reports of alarming <a href="https://www.theguardian.com/society/2023/feb/17/nhs-unsafe-sewage-leaks">sewage leaks</a> – 456 in 2022 – on to wards and A&E departments</p>
<p>Elsewhere, the emergency response 111 and <a href="https://www.nuffieldtrust.org.uk/resource/ambulance-response-times">999 call triage</a> systems have been shown to be <a href="https://committees.parliament.uk/writtenevidence/113092/pdf/">risk-averse tools</a>, which often default to sending more patients to hospitals and making more ambulance calls than needed. This only adds to the load on an already overloaded workforce. </p>
<p><a href="https://www.longtermplan.nhs.uk/areas-of-work/digital-transformation/">Digital transformation</a> to increase the range of tools and services is an important NHS priority. However, new calls for a technological revolution are frustrated by a history of <a href="https://www.theguardian.com/society/2013/sep/18/nhs-records-system-10bn">abandoned IT systems</a> costing more than £10 billion. This is in addition to <a href="https://ebm.bmj.com/content/23/5/161">challenges</a> posed by the built infrastructure and workforce training needed to make such a transformation happen.</p>
<p>The centralised model on which the NHS is built is not fit for purpose in 2023. Devolved healthcare, wherein individual trusts have greater <a href="https://www.kingsfund.org.uk/blog/2015/11/devolution-silver-bullet-swiss-cheese">autonomy</a> and flexibility, would serve the nation better. </p>
<p>Real progress will depend upon <a href="https://theconversation.com/nhs-plans-to-expand-virtual-wards-but-who-will-staff-them-198843">staff availability</a> in the community and <a href="https://www.nuffieldtrust.org.uk/news-item/social-care-reform-across-the-uk-why-does-it-keep-failing">genuine efforts</a> to reform and integrate health and social care – reforms which have been formulated, but not implemented. </p>
<p>Instead, the current system is complex and fragmented, with individual component institutions having competing proprieties and a <a href="https://www.theguardian.com/society/2023/jan/08/sick-man-of-europe-why-the-crisis-ridden-nhs-is-falling-apart">protectionist</a> approach to budgeting. Ultimately, without consensus between the two main political parties, this cannot be solved. Without answers, £2.6 billion will not be enough.</p><img src="https://counter.theconversation.com/content/199633/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paresh Wankhade is affiliated with Fire Services Research & Training Trust (FSRTT) as a Trustee.</span></em></p>The problems facing the NHS have been years in the making: a result of poor decision-making, lack of political consensus and chronic underinvestment.Paresh Wankhade, Professor of Leadership and Management, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1941972022-12-14T10:01:46Z2022-12-14T10:01:46Z‘It’s like being in a warzone’ – A&E nurses open up about the emotional cost of working on the NHS frontline<figure><img src="https://images.theconversation.com/files/499022/original/file-20221205-22-zuf5q1.jpeg?ixlib=rb-1.1.0&rect=53%2C35%2C2798%2C2480&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/tired-depressed-female-african-scrub-nurse-1761627959">Shutterstock/Ground Picture</a></span></figcaption></figure><p><strong>As nurses prepare to <a href="https://www.rcn.org.uk/news-and-events/Press-Releases/first-strike-dates-announced-by-rcn-after-uk-government-declines-nhs-pay-negotiations">strike</a> for the first time, an A&E nurse and lecturer in Organisational Behaviour in Healthcare writes about the stress, fear, grief and guilt they feel every day working on the frontline of an NHS in crises.</strong> </p>
<hr>
<blockquote>
<p>I noticed how I used the phrase ‘warzone’ quite a few times, when you’ve got trolleys everywhere … full of patients and you don’t know where to turn next. What to do for whom next, and I have said it’s like being in a warzone because you can imagine it. That’s what it would be like in a field hospital … what do I do next? You know it’s dangerous but you’ve just got to do the best you can do. And I’ve heard other people use that term as well. Just how it makes you feel but something kicks in and you just get on with it. </p>
</blockquote>
<p>This was how one nurse in her 40s described an Accident and Emergency (A&E) department to me, and it sounded all too familiar. </p>
<p>The resuscitation area in the emergency department is a hive of time-critical activity as staff weave around one another at pace. The sheer din is intense: a symphony of alarms, voices and crying out – all varying in pitch and volume, competing with one another. The bays are awash with wires, pipes, medical equipment and pumps to give various medication. </p>
<p>This is the norm. But some nights will always stand out above the others. Once, while I was on shift, a three-year-old girl in a nearby resuscitation bay was receiving treatment for meningitis. Following a substantial and sustained attempt at resuscitation by the paediatric team, she died. </p>
<p>I wasn’t caring for her directly, but it was apparent from the noise how the treatment was progressing and when, ultimately, it was unsuccessful. The screams and cries of grief from the girl’s parents were heard above all other noise when staff broke the news to them that their child was dead. It was unforgettable. </p>
<hr>
<p><strong><em>This story is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> and is working with academics from different backgrounds who have been engaged in projects to tackle societal and scientific challenges.</em></p>
<hr>
<p>Many of the adult patients were too unwell to know what was going on. So, despite the communal awareness among staff of the enormous distress close by, we carried on caring for our other patients, offering them the “reassuring face” and warmth they expected. I stood behind one of the curtains for a few moments and swallowed hard at the sounds of the suffering. And that was it. Sadness and distress at the death of a child had to be suppressed for the sake of the other patients.</p>
<p>On the drive home I reflected on the emotional complexity it requires to be a nurse. The need to hide sorrow while juggling great workloads, the pressure of organisational targets and other patients’ seemingly less critical needs requires intense effort and emotional control. That effort is exhausting and draining.</p>
<p>This tragic incident was just one of many similar experiences I have encountered over my 11-year career as an A&E nurse. Heartbreaking and emotionally complex stories like this happen every day in A&Es up and down the country. Nurses have to conceal myriad feelings as standard just to get through their shifts. This includes harrowing, disturbing and traumatic emotion as described in the story above, but also fear and anxiety when they feel overwhelmed and have to deal with aggressive situations. Nurses experience joy and relief when a patient recovers against the odds but frequent guilt and shame at being unable to deliver the standard of care they desire. </p>
<p>The exploration of emotional labour in emergency care has underpinned my <a href="https://doi.org/10.1111/jan.14765">subsequent</a> <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jan.15315">research career</a>. It has motivated me to explore and support this under-recognised area of nursing practice.</p>
<p>“<a href="https://www.ucpress.edu/book/9780520272941/the-managed-heart">Emotional labour</a>” is a theory coined by sociologist Arlie Hochschild who defines it as “the management of feeling to create a publicly observable facial and bodily display”. When that toddler died of meningitis, myself and the other nurses did our own emotional labour by suppressing our true emotions to ensure the other patients in our care felt reassured. In other words, we remained “professional”.</p>
<p>But the nurses I spoke to are not only dealing with emotions related to grief and bereavement. Because of the crisis facing the NHS, many feel they can’t do their job properly and so have overwhelming feelings of guilt too. A male nurse in his 30s told me: </p>
<blockquote>
<p>You can’t be the sort of nurse you might want to be … You can’t nurse people properly in the ED (emergency department) … You don’t have the staff or facilities to do that and it’s just getting worse … I think it’s one of the major things that make it a hard place to work because you feel that you’re not doing the best for the people you’re looking after … it can actually grind you down. As nurses, you want to care for people. You want to make a difference.</p>
</blockquote>
<figure class="align-center ">
<img alt="Black and white image of a nurse wearing a mask" src="https://images.theconversation.com/files/499018/original/file-20221205-21-ztu3dd.jpeg?ixlib=rb-1.1.0&rect=89%2C71%2C3431%2C3224&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499018/original/file-20221205-21-ztu3dd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499018/original/file-20221205-21-ztu3dd.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499018/original/file-20221205-21-ztu3dd.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499018/original/file-20221205-21-ztu3dd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499018/original/file-20221205-21-ztu3dd.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499018/original/file-20221205-21-ztu3dd.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A workforce in crisis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-black-white-young-female-surgeon-1703073148">Shutterstock/jotamadrid</a></span>
</figcaption>
</figure>
<h2>NHS in crisis</h2>
<p>A recent <a href="https://www.kingsfund.org.uk/press/press-releases/nhs-now-under-most-extreme-pressure-seen-recent-history#:%7E:text=Responding%20to%20the%20latest%20NHS,is%20battling%20on%20multiple%20fronts.">analysis</a> by The Kings Fund showed the extreme pressure the NHS is under. More patients than ever are experiencing delays in cancer diagnosis and treatment and <a href="https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/waiting-times-non-urgent-treatment">longer waiting times</a> in “non-urgent care”.</p>
<p>These pressures have an impact on patients, but also affect those tasked with delivering care. Nurses are <a href="https://www.theguardian.com/society/2022/may/18/numbers-of-nurses-and-midwives-leaving-nhs-highest-for-four-years">quitting in record numbers</a>. By 2030-31 half a million <a href="https://committees.parliament.uk/publications/6158/documents/68766/default/">extra healthcare staff</a> will be needed to meet the pressures of demand – a 40% increase in existing workforce. Health and social care staff are exhausted and the workforce is <a href="https://www.cqc.org.uk/press-release/gridlocked-health-and-care-system-leading-deterioration-peoples-access-and-experience">depleted</a>. The negative impact of this crisis cannot be underestimated for both staff and patients.</p>
<p>When nurse staffing is short or lacking in the required skills due to issues like high staff turnover and sickness, <a href="https://pubmed.ncbi.nlm.nih.gov/28626086/">research shows</a> that patient mortality is higher and patient experience is <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jocn.15242">poor</a>.</p>
<p>Nurses working in short-staffed areas are <a href="https://pubmed.ncbi.nlm.nih.gov/17064706/">twice as likely</a> to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care in their hospitals. This becomes a vicious cycle as these experiences fuel more staff to leave. </p>
<p><a href="https://www.nhsstaffsurveys.com/results/">Sickness absence rates</a> in the NHS are higher than in the rest of the economy and 47% of staff felt unwell in the last 12 months as a direct result of workplace stress. One study has shown levels of Post Traumatic Stress Disorder similar to those experienced <a href="https://inews.co.uk/news/health/nhs-intensive-care-staff-same-level-ptsd-covid-afghanistan-combat-veterans-1647786">by soldiers</a> in Afghanistan.</p>
<p>A <a href="https://covidandsociety.com/rapid-evidence-review-economic-analysis-nhs-staff-wellbeing-and-poor-mental-health/">recent evaluation</a> found that poor mental health and wellbeing among medical staff is costing the NHS about £12.1 billion per year.</p>
<h2>Accident and Emergency</h2>
<p>In England, NHS patient attendance to A&E has followed an upward trajectory over the last 70 years. In 2019-20 there were <a href="https://www.kingsfund.org.uk/blog/2022/11/health-inequalities-what-happening-emergency-medicine">25 million</a> attendances, compared to 21.5 million attendances in 2011-12.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1395310849485688833"}"></div></p>
<p>Patient attendance has been growing exponentially in the last ten years. This, together with <a href="https://www.kingsfund.org.uk/audio-video/key-facts-figures-nhs">rises</a> in patients who need admitting to hospital for routine care, <a href="https://www.kingsfund.org.uk/publications/nhs-hospital-bed-numbers">fewer</a> hospital beds and staffing pressures has resulted in unsafe patient <a href="https://www.bmj.com/content/375/bmj.n2835">overcrowding</a> in A&Es. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785211/">Research</a> has shown how overcrowding increases adverse clinical outcomes including death, medical error and decreased patient satisfaction.</p>
<p>The most recent <a href="https://www.nuffieldtrust.org.uk/resource/a-e-waiting-times#background">figures for 2022-23</a> show the worst A&E performance (waiting longer than four hours) on record.</p>
<p>Perhaps unsurprisingly then, those working in emergency care are more likely than other healthcare workers to experience <a href="https://pubmed.ncbi.nlm.nih.gov/25468279/">poor wellbeing</a>, suffer <a href="https://pubmed.ncbi.nlm.nih.gov/27729392/">psychological illness</a> and to <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2834.2012.01355.x">quit</a> their jobs.</p>
<h2>Nurses open up</h2>
<p>According to the Royal College of Physicians, NHS staff are the <a href="https://www.rcplondon.ac.uk/guidelines-policy/work-and-wellbeing-nhs-why-staff-health-matters-patient-care">greatest asset</a> of the NHS and are fundamental to delivering high-quality care. Staff go “<a href="https://www.kingsfund.org.uk/press/press-releases/nhs-now-under-most-extreme-pressure-seen-recent-history#:%7E:text=Responding%20to%20the%20latest%20NHS,is%20battling%20on%20multiple%20fronts">the extra mile</a>” as standard: they work without breaks, come in on their days off and often stay unpaid, long after shifts have finished.</p>
<p>My <a href="https://doi.org/10.1111/jan.15315">PhD</a> aimed to <a href="https://onlinelibrary.wiley.com/doi/10.1111/jan.14765">understand</a> the experiences of nursing staff in A&Es and how they managed their emotions to cope with these challenges and still meet patient expectations. This is critical because emotional labour, in particular, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5823819/">is linked</a> to wellbeing and burnout. </p>
<p>I worked with a team of academics to undertake an ethnographic observation study across two large NHS trusts in the UK. This involved 200 hours of observation and 36 in-depth interviews. We spoke to A&E nurses of all seniority and support staff in both organisations. We found that the nursing staff “did” intense emotional labour routinely in their work. As one male nurse in his 30s explained:</p>
<blockquote>
<p>… you know, you see quite a lot of bad things. You deal with a lot of complex things and … you do have to put up a front, a very professional front, and you have to deal with different levels of communication as well. You’ll get someone with mental health problems one minute, get someone with a broken finger the next minute, someone’s collapsed … Then you just have to mould yourself into a different personality … to communicate with [each patient], to get on their level of need … you’ve got to go from zero to hero, as far as I’m concerned … Never knowing somebody to doing something really, really intimate … So you’ve got to get to know them really quickly, for them to be able to trust you.</p>
</blockquote>
<p>The nurses adapted their emotional response to support a vast spectrum of patient need. Among these complex and intense emotions, we heard examples of nurses who felt scared, guilty and endless examples of nurses being short on time and resource, feeling stressed, and grieving over patients who died. They hid their true feelings to make sure their patients felt safe and to build trust – whatever the circumstances. They moved at pace between groups of patients and adapted their appropriate “professional” response. </p>
<p>We collected data over a six-month period and found that the nurses used various metaphors to describe experiences of managing their emotion in A&E. We found some key themes.</p>
<h2>Guilt and shame</h2>
<p>Nurses described to us how sometimes the environment can feel overwhelming, using that “warzone” phrase to explain their experiences. This sense of relentlessness and “combat” has implications for the nurses emotional labour too. Their nursing values (related to providing care and compassion) are conflicted with the realities of contemporary practice. The standards of care possible amid the operational pressures don’t reflect these nursing values (built on warm and reassurance).</p>
<p>The nurses I spoke to weren’t able to deliver the quality of care they wanted to. This means they needed to suppress the associated frustration and guilt. There was a sense of genuine sadness and even shame that they couldn’t give their patients the time or connection they longed to.</p>
<p>This former nurse said one incident in particular “changed her outlook on A&E” and led to her thinking, “I can’t work here anymore”.</p>
<blockquote>
<p>It was a really, really busy winter day … trolleys were stacked … and right in the middle I had a little old lady in her 90s who suddenly deteriorated and I could do nothing but stand in the middle of all the trolleys, in front of all of those people, holding her, shouting for help. I just thought that if that was my grandmother, I’d be disgusted.</p>
</blockquote>
<h2>Assembly line</h2>
<p>Instead of meaningful patient and nurse relationships, the care delivered in A&E often feels transactional and lacking emotional connection. Interactions were quick and task based. Again this results in the nurses feeling dissatisfied and often guilty. <a href="https://www.surrey.ac.uk/people/jill-maben">Jill Maben</a>, a professor of health services and nursing, <a href="https://pubmed.ncbi.nlm.nih.gov/17518822/">found</a> that when nurses are unable to deliver the care they want to, it doesn’t line up with their values. This disconnect (between values and reality) can be a reason why nurses leave the profession.</p>
<p>The clinical realities of the nurses work went against their deep moral values and the desire to care. This was reflected by many of the nurses I met, including a female nurse in her 40s, who said: </p>
<blockquote>
<p>I’ve actually used that term assembly line – it’s like a production line of patients … you’ve got [ambulance] crews coming in constantly … You take handover from the crew, do the basics, move on to your next patient. Take handover, do the basics, move on to your next patient. You might not even see that patient again … it means there’s a definite lack of care there … I go home feeling very unsatisfied because you’ve not cared for people, you’ve just checked their observations, given them any immediate treatment they need, but the actual caring aspect of it, you’ve not really done any of that.</p>
</blockquote>
<p>For some of the A&E nurses interviewed in the study, the inability to deliver the standard of care they wanted to was unmanageable and they left. One told me she quit because A&E was so busy it meant ignoring some people who were waiting long hours. She said:</p>
<blockquote>
<p>I think you need to be quite stony-hearted because it’s a hard place to work … I care too much. I can’t walk past somebody that says ‘can you help me?’ and unfortunately you don’t have time. In A&E, you don’t have time to stop for every person who says ‘excuse me’. You need to be able to walk past people …</p>
</blockquote>
<h2>Stress and fear</h2>
<p>Sometimes the nurses said they were scared: scared of the overwhelming workload as well as the threats and intimidation they received from patients. One of the nurses, in her early 20s, described how she “put on a front” to her patients. She did this to hide any anxiety around her inability to cope. She was protecting her patients from her true emotion and as a result, making sure they felt safe:</p>
<blockquote>
<p>I suppose from the outside it could appear that you’re managing well, you’re getting to your patients, you’re putting on a front, you’re smiling, you’re happy. You present yourself. You tell them what the plan is, what’s going to happen, what to expect next. Then you’re whisking off to take the next patient or moving on to another area. So, yeah … patients’ or relatives’ perception could be that it doesn’t look as busy because they don’t see what’s going on behind the scenes. They don’t see what resus [resuscitation] is like, that there’s minus three beds in there … Or the walk-in side … there could be probably five or six people in the waiting room wanting to know why they’ve not been seen straightaway because it doesn’t look busy, whereas resus is just behind the doors and there could be massive traumas going off.</p>
</blockquote>
<p>She said it was important not to let patients see that they were “stressed and flustered” because “it gives them reassurance … to show patients that you’re confident and you can get on with it”.</p>
<p>Again the nature of this emotional labour (this time suppressing fear and anxiety) is guided, in part by the need to protect and reassure patients under their care. Another nurse, in his 30s added:</p>
<blockquote>
<p>…you’re actually like a parent to everybody. You’re everybody’s mum or dad. So on the surface you do have to look calm and you have to look like you’re in control because they’re vulnerable and you can’t be panicking because it’s just not going to solve anything, whereas underneath you might not have a clue what to do, but you have to come up with something and you might be crapping yourself … it’s just a mask, isn’t it?</p>
</blockquote>
<p>For some, the extraordinary feeling of stress involved is overwhelming but the nurses stay calm and professional outwardly, as described by a female nurse in her 30s: </p>
<blockquote>
<p>It’s a mixture of stress. Sometimes you just feel like you just don’t know where to start. Sometimes in the environment where it’s overcrowded like that, you can feel very enclosed and it can feel quite pressurised because … you can feel like everyone is looking at you.</p>
</blockquote>
<p>She added that the same amount of pressure and noise could amount to “torture” for some people.</p>
<p>But sometimes the stress was related to fear and anger when dealing with an aggressive and abusive patient. Again the nurses emotion remained hidden and out of sight of the patient and others in the waiting room. One nurse described an incident on a particularly busy night with man who was getting tired of waiting with a minor injury.</p>
<p>She offered him assistance, as he was struggling to walk. But he shouted at her in front of a full waiting room, including children: “Why don’t you just fuck off and die?”</p>
<figure class="align-center ">
<img alt="Graphic of a nurse feeling stressed." src="https://images.theconversation.com/files/499020/original/file-20221205-26-lr7xk1.jpeg?ixlib=rb-1.1.0&rect=104%2C404%2C2219%2C2035&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499020/original/file-20221205-26-lr7xk1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499020/original/file-20221205-26-lr7xk1.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499020/original/file-20221205-26-lr7xk1.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499020/original/file-20221205-26-lr7xk1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499020/original/file-20221205-26-lr7xk1.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499020/original/file-20221205-26-lr7xk1.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The ‘emotional labour’ it can take to be a nurse can lead to burnout.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/concept-medical-front-line-health-workers-1893347266">Shutterstock/OlenasArt</a></span>
</figcaption>
</figure>
<p>The nurse was shocked. The entire waiting room was staring back at her. She said she couldn’t speak and that her “blood was boiling” but she was also frightened. She couldn’t engage with him so she walked away, afraid she would shout back or cry if she tried to speak. “Had I been outside of work, I wouldn’t let people speak to me like that,” she said. </p>
<p>She added that if those unruly and abusive patients were shown a baby being resuscitated in the next room they might rethink their behaviour and show more respect. </p>
<h2>Grief and trauma</h2>
<p>But all feelings must be managed, even sadness and grief – perhaps these emotions above all.</p>
<blockquote>
<p>If you came into [A&E] and a nurse started blubbering because of your story, what would you feel like as a patient? So, we probably are good at emotions but actually we’re good at not showing them. It doesn’t mean to say we don’t feel them … The more competent you become as a nurse, the more you actually learn that you have to suppress that … If you get a baby that comes in and the parents are screaming and crying, they don’t want the nurse doing the same thing. They want the nurse to be efficient, to know what they’re doing and to assist them. They do not need an emotional wreck to be dealing with them.</p>
</blockquote>
<p>This female nurse said that managing emotions like this meant some nurses might sometimes come across as “hard” and “cold”.</p>
<p>But being able to relate personally to the patient or their family, although helpful for the patient, can take a heavy toll on the nurse. One nurse got upset when telling me about the time she was pregnant with her little boy and was resuscitating a baby.</p>
<blockquote>
<p>Yeah. That was a baby. It sticks with you. It definitely does. I was looking after another one … that was having seizures. It was a one-year-old little one in resus, and when I finished my shift, I’d gone home, but it was on my mind all night and I was wanting to ring back and check. Obviously, I’ve got no connection to that little one … you can relate it to your own children as well, put yourself in those parents’ shoes.</p>
</blockquote>
<h2>Compassion fatigue</h2>
<p>Operational pressures in A&E and elsewhere in the health service squeeze the time nurses have with their patients. The fact many are unable to deliver the standard of care they long to contributes to nurses leaving the profession as described above.</p>
<p>And those nurses who stay can become so burned out that they can suffer with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924075/">compassion fatigue</a>: a protective mechanism in which nurses become emotionally “shut down” and as a result, can fail to notice and respond accordingly to trauma and suffering. This shows that the health – particularly the mental health – of nurses and doctors can directly impact patient care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-will-not-forget-our-colleagues-who-have-died-two-doctors-on-the-frontline-of-the-second-wave-148152">'We will not forget our colleagues who have died': two doctors on the frontline of the second wave</a>
</strong>
</em>
</p>
<hr>
<p>We need to understand the emotional complexity of nursing and other healthcare work. In understanding it, we can value it. </p>
<p>Nurses are not <a href="https://www.bbc.co.uk/news/uk-wales-61412032">angels</a>, they are human beings, with the accompanying full spectrum of emotions. At their best they can offer life-changing support and compassion. But they need the resources and support. There is only so much stress, fear, grief and trauma a person can cope with before burning out completely. </p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
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<li><p><em><a href="https://theconversation.com/my-work-investigating-the-links-between-viruses-and-alzheimers-disease-was-dismissed-for-years-but-now-the-evidence-is-building-184201">My work investigating the links between viruses and Alzheimer’s disease was dismissed for years – but now the evidence is building</a></em></p></li>
<li><p><em><a href="https://theconversation.com/noise-in-the-brain-enables-us-to-make-extraordinary-leaps-of-imagination-it-could-transform-the-power-of-computers-too-192367">Noise in the brain enables us to make extraordinary leaps of imagination. It could transform the power of computers too</a></em></p></li>
<li><p><em><a href="https://theconversation.com/londons-olympic-legacy-research-reveals-why-2-2-billion-investment-in-primary-school-pe-has-failed-teachers-178809">London’s Olympic legacy: research reveals why £2.2 billion investment in primary school PE has failed teachers</a></em></p></li>
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<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/194197/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Kirk was funded by Health Education England (HEE) / NIHR for this research project. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.</span></em></p><p class="fine-print"><em><span>Laurie Cohen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nurses describe what it is like to work on the NHS frontline – and what the cost is to them.Kate Kirk, Lecturer in Organisational Behaviour in Healthcare, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1946432022-12-01T02:46:43Z2022-12-01T02:46:43ZWhy do nurse home visits stop a few weeks after giving birth? Extending them to 2 years benefits the whole family<figure><img src="https://images.theconversation.com/files/498167/original/file-20221130-26-xgedg.jpg?ixlib=rb-1.1.0&rect=35%2C17%2C5955%2C3970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/mother-with-baby-in-arms-7282407/">Pexels/Sarah Chai</a></span></figcaption></figure><p>Bringing home a new baby can be one of the most exciting and stressful times in your life. A nurse might visit a couple of times, then other than routine check-ups at the nurse’s office, you’re largely on your own. </p>
<p>Some people have a particularly hard time with a new baby because the challenges of parenting come on top of existing adversity, such as financial hardship, or poor physical or mental health. </p>
<p>Experiencing adversity from when a baby is conceived can affect the child’s <a href="https://www.rch.org.au/uploadedFiles/Main/Content/ccchdev/CCCH-The-First-Thousand-Days-An-Evidence-Paper-Summary-September-2017.pdf">health and development</a> as they grow older. So rather than stopping nurse visits a week or two after bringing a new baby home, we investigated whether extending these visits from pregnancy until children turned two made a difference. </p>
<p>The nurse visits focused on areas fundamental for children’s development: how a parent cares for and responds to their child, and their home environment. </p>
<p>We found home visits with nurses helps parenting and family relationships, and women’s mental health, wellbeing and confidence.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1380610832485154816"}"></div></p>
<h2>What happens when the nurse visits?</h2>
<p>Sustained nurse home visiting provides intensive services in a family’s home during pregnancy and the first two years of the child’s life. During this time, the child’s brain develops more rapidly than any other time in their life. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-i-know-if-my-child-is-developing-normally-129137">How do I know if my child is developing normally?</a>
</strong>
</em>
</p>
<hr>
<p>International studies of sustained nurse home visiting programs show <a href="https://onlinelibrary.wiley.com/doi/10.1111/jan.14576">they can help families</a> with parenting, children’s behaviour and academic skills. However, most have only measured impacts up to when children turn three. </p>
<p>Programs differ depending on how they work to support families. They generally engage highly-trained nurses who can listen without judgement, offer practical, evidence-informed advice, and remind parents they’re doing a good job.</p>
<h2>Our study</h2>
<p>Our randomised controlled trial of <a href="https://www.rch.org.au/ccch/research-projects/right-at-home/">right@home</a> is Australia’s longest and largest trial of nurse home-visiting, starting in 2013. </p>
<p>The program supports parents with evidence-based techniques that promote parenting that responds to the child’s needs, safe homes, regular routines, and children’s learning and language development. The program starts in pregnancy and offers 25 home visits (60-90 minutes each) with a specially trained nurse until the children turn two. </p>
<p>The right@home program was designed for delivery through Australia’s existing child and family health nursing services, which are free for families with children from birth to school age. These existing services typically offer a handful of appointments (of around 20-40 minutes) that mostly take place in local clinics. Some also offer more intensive services.</p>
<figure class="align-center ">
<img alt="Toddler reads from a board book" src="https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Existing nurse services only offer a handful of appointments from birth to school age.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/u0zTce7KNlY">Unsplash/Stephen Andrews</a></span>
</figcaption>
</figure>
<p>We invited women into the right@home study if they were experiencing two or more factors that can make it more difficult to parent. These include having low social support, poor physical or emotional health, or no household employment. We found <a href="https://onlinelibrary.wiley.com/doi/10.1111/jpc.13860">almost 40%</a> of pregnant women experienced at least two of these factors. </p>
<p>In total, 722 women and families living across Victoria and Tasmania took part in the study. Half were randomly allocated (like tossing a coin) to receive the right@home program and half received their local child and family health nursing service. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/parents-have-the-biggest-influence-over-their-childs-language-and-emotional-development-55823">Parents have the biggest influence over their child's language and emotional development</a>
</strong>
</em>
</p>
<hr>
<h2>What did we find?</h2>
<p>Researchers who were separate to the nurse teams interviewed the families twice a year (one at home and one by phone) until children started school. </p>
<p>When the right@home program ended (at children’s second birthdays), the evaluation showed it <a href="https://doi.org/10.1542/peds.2018-1206">offered benefits</a> over and above the usual services. Parents had more confidence and skills in caring for their children, responding sensitively and providing a nurturing and stimulating home. </p>
<p>This pattern <a href="https://publications.aap.org/pediatrics/article/147/2/e2020025361/77055/Nurse-Home-Visiting-and-Maternal-Mental-Health-3">continued</a>. At three years, parents who received the right@home program reported benefits to their mental health, wellbeing, and self-confidence. </p>
<figure class="align-center ">
<img alt="Parents snuggle their newborn baby" src="https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nurses can remind new parents they’re doing a good job.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/cheerful-young-multiethnic-parents-admiring-sleeping-baby-on-bed-6392952/">Pexels/William Fortunato</a></span>
</figcaption>
</figure>
<p>Our latest paper, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0277773">published in PLOS ONE</a>, shows that right@home offered lasting impacts to four and five years, which is two and three years after the program ended. </p>
<p>Some 5-10% more families had regular mealtimes, bedtimes and bedtime routines by the time the children turned five.</p>
<p>Around 9% more women reported very good health and parenting confidence. The proportions of women experiencing stress, and emotional abuse from an intimate partner were 7% and 11% lower, respectively. </p>
<p>There were additional benefits for children’s and women’s mental health, parenting, and women’s wellbeing, quality of life and relationship with their child. These impacts were evident for families regardless of where they lived across the seven regional and metropolitan areas in the two states.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/having-problems-with-your-kids-tantrums-bed-wetting-or-withdrawal-heres-when-to-get-help-125299">Having problems with your kid's tantrums, bed-wetting or withdrawal? Here's when to get help</a>
</strong>
</em>
</p>
<hr>
<h2>Levelling the playing field for kids</h2>
<p>A goal of the program is to address the challenging circumstances that disrupt parenting and affect children’s health and development.</p>
<p>If Australia did this, and provided support according to need, we could reduce children’s poor developmental outcomes by <a href="https://doi.org/10.1093/ije/dyy087">50%-70%</a>.</p>
<p>Providing equitable support is especially important as we <a href="https://bmjpaedsopen.bmj.com/content/6/1/e001390">emerge from the COVID pandemic</a>, which has <a href="https://doi.org/10.5694/mja2.51368">disproportionately affected</a> families already experiencing adversity. </p>
<figure class="align-center ">
<img alt="Mother wipes ice cream from her daughter's chin" src="https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Greater early support boosts mothers’ mental wellbeing.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/attentive-asian-mother-cleaning-face-of-cute-daughter-5094378/">Kamaji Ogino/Pexels</a></span>
</figcaption>
</figure>
<p>Almost no other public health program delivered during the early years has evidence of such a broad range of gains. </p>
<p><a href="https://bmjopen.bmj.com/content/11/12/e052156">Our economic evaluation</a> of right@home at three years showed delivering these benefits through the right@home program costs A$7,700 extra per family compared with the usual service.</p>
<p>Research from the US shows the benefits of <a href="http://www.wsipp.wa.gov/BenefitCost/Program/35">similar programs</a> accrue for families and taxpayers over a child’s lifetime, producing positive returns on investment, from improved mental health and more employment, among other benefits.</p>
<p>Australia is fortunate to have nationwide child and family health nursing services. These are the perfect platform for delivering an extended program like right@home. When so few programs make a difference for families experiencing adversity, we should maximise the reach of those that do.</p>
<p><em>Diana Harris, Lead for Knowledge Translation at the Australian Research Alliance for Children & Youth, coauthored this article.</em></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/stressed-about-managing-your-childs-behaviour-here-are-four-things-every-parent-should-know-104481">Stressed about managing your child's behaviour? Here are four things every parent should know</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/194643/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>right@home is supported by the state governments of Victoria and Tasmania, the Ian Potter Foundation, Sabemo Trust, Sidney Myer fund, the Vincent Fairfax Family Foundation, and the National Health and Medical Research Council (NHMRC, 1079148). The MCRI administered the research grant for the study and provided infrastructural support to its staff but played no role in the conduct or analysis of the trial. Research at the MCRI is supported by the Victorian Government's Operational Infrastructure Support Program. SG was supported by NHMRC Practitioner Fellowship (1155290).
The “right@home” sustained nurse home visiting trial is a research collaboration between the Australian Research Alliance for Children and Youth (ARACY); the Translational Research and Social Innovation (TReSI) Group at Western Sydney University; and the Centre for Community Child Health (CCCH), which is a department of The Royal Children's Hospital and a research group of Murdoch Children’s Research Institute. Ownership of the right@home implementation and support license, which is purchased by Australian state governments for roll out for fidelity support, is shared between institutes.</span></em></p><p class="fine-print"><em><span>The MECSH home visiting program upon which right@home is based is trademarked and licenced by Western Sydney University and was developed by UNSW Australia. Western Sydney University is a member of the right@home consortium that receives funding from Australian state governments to support the implementation of the program. Western Sydney University also licenses the MECSH program to government and non-government providers of home visiting services in the UK and USA. </span></em></p><p class="fine-print"><em><span>Sharon Goldfeld receives funding from ARC and NHMRC.</span></em></p>Extending visits from nurses who can listen without judgement and offer practical, evidence-informed advice helps new parents who are experiencing adversity.Anna Price, The Erdi Foundation Child Health Equity (COVID-19) Scholar, Centre for Community Child Health | Honorary, Department of Paediatrics, University of Melbourne | Team Leader / Senior Research Officer, Murdoch Children's Research InstituteLynn Kemp, Director of the Translational Research and Social Innovation group, School of Nursing and Midwifery, Western Sydney UniversitySharon Goldfeld, Director, Center for Community Child Health Royal Children's Hospital; Professor, Department of Paediatrics, University of Melbourne; Theme Director Population Health, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1848292022-08-11T23:18:12Z2022-08-11T23:18:12ZGetting more men into nursing means a rethink of gender roles, pay and recognition. But we need them urgently<figure><img src="https://images.theconversation.com/files/474236/original/file-20220715-11-w83sqo.jpg?ixlib=rb-1.1.0&rect=0%2C70%2C6720%2C4396&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Demand for health care is soaring as the population ages, medical treatments become more widely available and more people live with chronic and complex illnesses.</p>
<p>However, there is global <a href="https://www.who.int/health-topics/health-workforce#tab=tab_1">shortage of health professionals</a> – and the pandemic has only accentuated the trend. Overwork, burnout and stress are causing nurses to <a href="https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/assessing-the-lingering-impact-of-covid-19-on-the-nursing-workforce">leave in droves</a>. </p>
<p>The World Health Organization <a href="https://www.who.int/news-room/fact-sheets/detail/nursing-and-midwifery">estimates</a> we’ll need a further 9 million nurses worldwide by 2030. According to the International Council of Nurses, the figure is closer to <a href="https://www.icn.ch/sites/default/files/inline-files/ICN%20Policy%20Brief_Nurse%20Shortage%20and%20Retention_0.pdf">13 million</a>.</p>
<p>Part of the solution is to recruit and retain more men in nursing. This would help address workforce shortages and could, over time, reduce the industry gender pay gap as the existence of men in nursing becomes more normalised. </p>
<p>And as jobs dry up in traditionally male-focused industries – such as mining and manufacturing – work in health care should be an <a href="https://nurse.org/articles/Male-Nurses-And-The-Profession/">attractive option</a> for men, providing job security, career opportunities and salary. </p>
<p>But attracting men to the profession won’t be without its challenges. It will require a serious society-wide rethink around gender roles, compensation and recognition for the importance of nursing work.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477275/original/file-20220803-26-98lqfz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/477275/original/file-20220803-26-98lqfz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477275/original/file-20220803-26-98lqfz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477275/original/file-20220803-26-98lqfz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477275/original/file-20220803-26-98lqfz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477275/original/file-20220803-26-98lqfz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477275/original/file-20220803-26-98lqfz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477275/original/file-20220803-26-98lqfz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The reasons for the low number of men in nursing are complex and multifaceted.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fixing-the-aged-care-crisis-wont-be-easy-with-just-5-of-nursing-homes-above-next-years-mandatory-staffing-targets-184238">'Fixing the aged care crisis' won't be easy, with just 5% of nursing homes above next year's mandatory staffing targets</a>
</strong>
</em>
</p>
<hr>
<h2>Why are there so few men in nursing?</h2>
<p>Caregiving is <a href="https://link.springer.com/article/10.1186/s12960-019-0406-0">feminised</a> in society and health care, and the nursing profession has strong female foundations. This has established a trajectory and a culture that has kept the representation of men to <a href="https://www.acn.edu.au/nurseclick/men-in-nursing-why-its-okay-for-men-to-care">around</a> <a href="https://www.bbc.com/news/uk-scotland-48125231">10%</a> in many high income countries.</p>
<p>This is despite fervent efforts by many in the industry to achieve the <a href="https://www.bls.gov/cps/cpsaat11.htm">equity of gender representation</a> you see in most professions. </p>
<p>The reasons are complex and multifaceted. Men in nursing are often portrayed negatively in <a href="https://www.truthaboutnursing.org/media/films/meet_the_parents.html#gsc.tab=0">media and movies</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/24001311/">Stereotypes</a> abound. </p>
<p>And some men in nursing face <a href="https://journals.lww.com/ajnonline/Citation/2006/02000/Men_in_Nursing__Still_Too_Few__Discrimination_and.16.aspx">discrimination</a> from patients and staff, underpinned by false assumptions women are better suited to the role. Many people still <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228905/">underestimate</a> the capacity of men to undertake personal care tasks.</p>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/nuf.12504?casa_token=0fSzo6BonEQAAAAA%3AuEbtIqONQ7FdzpbrezYLGoIEKLH37CbOan7R0n33MG4vBGplDO0PlJ4kcjEIHhp1hXlxKlEqCgEd">Research</a> also shows low male participation can stem from reticence by career counsellors to recommend nursing as a career.</p>
<p>A recent Australian <a href="https://www.health.gov.au/sites/default/files/documents/2019/12/topic-2-nursing-as-a-career-choice.pdf">report</a> shows the dominance of women in the nursing workforce may hinder some men from considering nursing as a career, particularly those for whom masculinity is central to their identity. So we must work to undo the perception nursing is a feminine job – it is not.</p>
<p>Negative perceptions around the prestige of nursing and its perceived status in the community may hinder some men’s interest in nursing as a career.</p>
<p>Good role modelling is important. Many educational institutions and supporters such as <a href="https://nursing.jnj.com/">Johnson & Johnson</a> are working hard to in present <a href="https://nursing.gwu.edu/improving-mens-health-battling-stereotypes">positive images</a> of men in nursing and normalise that men can be great nurses too.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/WikQz4J9B7U?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Source: JHU.</span></figcaption>
</figure>
<h2>Retaining men in the workforce and addressing the ‘glass escalator’</h2>
<p>Many <a href="https://www.who.int/publications/i/item/9789240003279">regulatory</a> and professional bodies are monitoring the participation of men in nursing. Some organisations offer incentives. For example, <a href="https://www.aamn.org/">The American Association for Men in Nursing</a> offers scholarships, awards and training to attract and retain men in the profession.</p>
<p>It is important to recognise some barriers for men come from within the nursing profession itself. </p>
<p>Some in the nursing workforce perceive that men are on a career “<a href="https://journals.lww.com/naqjournal/Abstract/2021/10000/Going_Up___Exploring_the_Phenomenon_of_the_Glass.6.aspx#:%7E:text=The%20%E2%80%9Cglass%20escalator%E2%80%9D%20refers%20to,to%20upper%20levels%20of%20leadership">glass escalator</a>”. Unlike a “glass ceiling”, which inhibits career progression, the “glass escalator” allows men to be fast-tracked up the nursing workforce to higher positions in an effort to retain them.</p>
<p>This can cause some to <a href="https://journals.lww.com/naqjournal/Abstract/2021/10000/Going_Up___Exploring_the_Phenomenon_of_the_Glass.6.aspx#:%7E:text=The%20%E2%80%9Cglass%20escalator%E2%80%9D%20refers%20to,to%20upper%20levels%20of%20leadership">perceive</a> male participation in nursing as a negative, which reduces inclusion. </p>
<p>But this glass escalator phenomenon, which can occur in <a href="https://www.spglobal.com/esg/csa/yearbook/articles/gender-equality-workplace-going-beyond-women-on-the-board">other industries</a> too, can only be overcome if male participation in the workforce is normalised. </p>
<p>And it is critically important to look at the structural, gender-driven factors that inhibit women embracing leadership roles. </p>
<p>It’s also worth noting women in the health and caregiving sector face a larger gender pay gap than in other economic sectors. A joint report by the International Labour Organization and the World Health Organization found: </p>
<blockquote>
<p>Women in the health and care sector face a larger gender pay gap than in other economic sectors, earning on average of 24% less than peers who are men […] Within countries, gender pay gaps tend to be wider in higher pay categories, where men are over-represented. Women are over-represented in the lower pay categories.</p>
</blockquote>
<p>Although this differential is not easily explained, it does reflect the value society ascribes to caregiving. If women are over-represented in the lower pay categories (which tend to focus more on personal care tasks) that suggests society ascribes low value to caregiving tasks, and over-representation of women in caregiving helps to further “feminise” caregiving.</p>
<p>It is highly likely these factors conspire to dissuade men and boys from getting started in nursing and undertaking caregiving roles within the profession.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477278/original/file-20220803-25-gs9o51.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/477278/original/file-20220803-25-gs9o51.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477278/original/file-20220803-25-gs9o51.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477278/original/file-20220803-25-gs9o51.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477278/original/file-20220803-25-gs9o51.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477278/original/file-20220803-25-gs9o51.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477278/original/file-20220803-25-gs9o51.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477278/original/file-20220803-25-gs9o51.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">We urgently need more men in nursing.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Time for action</h2>
<p>We urgently need more men in nursing. </p>
<p>Not only does this make good sense for health care, as it presents opportunities for engagement with men, but also good sense for our society and economic productivity. Investment in education and job creation in the health and social sectors <a href="https://www.who.int/teams/high-level-commission-on-health-employment-and-economic-growth/recommendations">could improve</a> health outcomes, shore up global health security, and boost inclusive economic growth.</p>
<p>Perhaps most importantly, robust health care systems should be representative of the populations they serve. The workforce in any industry should be drawn from a range of perspectives, including gender and culture. </p>
<p><hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-saints-or-monsters-pop-cultures-limited-view-of-nurses-107696">Friday essay: saints or monsters, pop culture's limited view of nurses</a>
</strong>
</em>
</p>
<hr>
</p><img src="https://counter.theconversation.com/content/184829/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patricia Davidson is Vice Chancellor and President of the University of Wollongong and is Dean Emerita at the Johns Hopkins School of Nursing. She has previously received funding from the National Health & Medical Research Council, Australian Research Council, National Heart Foundation, NSW Cancer Institute and National Institutes for Health in the United States. </span></em></p><p class="fine-print"><em><span>Caleb Ferguson works for the School of Nursing, University of Wollongong, NSW, Australia. He receives funding from the National Health & Medical Research Council, and has received funding from the Stroke Foundation and Heart Foundation.
</span></em></p><p class="fine-print"><em><span>Jason Farley works for Johns Hopkins University School of Nursing. He receives funding from the National Institutes of Health, Baltimore City Health Department, and the Centers for Disease Control and Prevention. </span></em></p>Research shows low male participation in the nursing workforce can stem from many sources, including reticence by career counsellors to recommend nursing as a career.Patricia Davidson, Vice-Chancellor, University of WollongongCaleb Ferguson, Associate Professor, University of WollongongJason Farley, Professor, Infectious Disease-Trained Epidemiologist and Nurse Practitioner, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1845052022-06-13T13:43:18Z2022-06-13T13:43:18ZBurned-out heroes: why bedside nurses should not have to be martyrs to be valued<p>In 2020, we saw windows pasted with rainbows, hospitals flooded with donations and NHS workers regularly <a href="https://theconversation.com/nurses-dont-want-to-be-hailed-as-heroes-during-a-pandemic-they-want-more-resources-and-support-167763">described as heroes</a>. While linked to <a href="http://doi.org/10.1136/medethics-2020-106398">heightened risks</a> faced by health workers during the pandemic, notions of self-sacrifice in nursing are not new. In fact, they have long underpinned the very nature of the role. </p>
<p>With the professionalisation of care work in the 19th century, in a society where a woman’s role was defined by caregiving, nurses were considered married to the job. Like military or monastic life, nurses were expected to not only suffer hardships without complaint but embrace them as part of <a href="https://theconversation.com/nurses-on-the-front-lines-a-history-of-heroism-from-florence-nightingale-to-coronavirus-137369">your life’s service</a>. </p>
<p>As written by E Glover, in a letter to the <a href="https://victoriancollections.net.au/items/6034a2bbacc7b00d389f7323">Nursing Journal</a>, published in 1903: </p>
<blockquote>
<p>A good nurse can never be compensated by money, She must be paid … but her work must be something better, something higher, and I may add purer and holier than the ordinary commerce of today.</p>
</blockquote>
<figure class="align-center ">
<img alt="A scene in a 19th century hospital ward, in black and white." src="https://images.theconversation.com/files/468240/original/file-20220610-28923-53ga7v.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/468240/original/file-20220610-28923-53ga7v.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/468240/original/file-20220610-28923-53ga7v.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/468240/original/file-20220610-28923-53ga7v.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/468240/original/file-20220610-28923-53ga7v.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/468240/original/file-20220610-28923-53ga7v.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/468240/original/file-20220610-28923-53ga7v.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If medicine has long been seen as a professional specialism, nursing has been sidelined – and undervalued – as an altruistic vocation.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Baron_Lister_%28seated%29_with_his_staff,_Victoria_ward,_King%27s_Wellcome_V0027907.jpg">Wellcome Images | Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Women’s and workers’ rights have come a long way since then. Yet bedside nurses’ role, job autonomy and even salaries are still defined by the notion that, as naturally compassionate individuals, they should be willing to sacrifice parts of themselves to provide care to others.</p>
<p>“Bedside nursing” refers to direct patient care and includes registered, associate and assistant nurses across a range of settings. The majority work day and night shift patterns and are not paid above band six (at which level, you can earn <a href="https://www.healthcareers.nhs.uk/working-health/working-nhs/nhs-pay-and-benefits/agenda-change-pay-rates/agenda-change-pay-rates">a maximum of £39,027</a>, once you have over five years of experience). Above that, you move into management or become a specialist practitioner.</p>
<p>Over my 15 years of working bedside, I have seen hundreds of ward staff experience <a href="https://theconversation.com/high-rates-of-covid-19-burnout-could-lead-to-shortage-of-health-care-workers-166476">burnout</a>. My doctoral <a href="https://www.ucl.ac.uk/anthropology/people/rebecca-williams">research</a> into ward-based care distribution shows how bedside nurses are particularly vulnerable to distress and burnout. Such stresses are only compounded by hero narratives.</p>
<h2>The enduring ideal of nursing as a calling</h2>
<p>The historic division of employment by gender and class underpins a <a href="https://www.routledge.com/Nursing-History-and-the-Politics-of-Welfare/Rafferty-Robinson/p/book/9780415138369">hierarchy of labour</a> within modern healthcare systems. Despite performing the majority of patient care and being subject to the most risk, bedside nurses occupy the lowest clinical pay bands.</p>
<p>Medicine has long been considered a professional specialism. Nursing, conversely, was seen as a vocation. This is rooted in the idea that care work is <a href="https://pubmed.ncbi.nlm.nih.gov/8970856/">altruistic</a>, and that caring is a disposition – not a skill.</p>
<p>Following this traditional demarcation between cure and care, the continued efforts of regulators and unions to cement nursing as a <a href="https://www.taylorfrancis.com/chapters/edit/10.4324/9780203864319-8/challenge-nursing-anne-witz-ellen-annandale">skilled profession</a> have, sadly, led to an increased devaluation of direct patient care and bedside nursing. </p>
<p>With diagnostic and life-promoting treatments prioritised, the fundamentals of healthcare – observation, hygiene, nutrition and comfort – are framed as the basics and, therefore, least valuable. This is defined by a pay structure that effectively rewards staff financially for moving away from bedside nursing and into a nine-to-five role, despite their having the biggest direct impact on patient care outcomes. </p>
<figure class="align-center ">
<img alt="A nurse in green scrubs holds up a poster demanding better pay." src="https://images.theconversation.com/files/468267/original/file-20220610-20-kj24ws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/468267/original/file-20220610-20-kj24ws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/468267/original/file-20220610-20-kj24ws.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/468267/original/file-20220610-20-kj24ws.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/468267/original/file-20220610-20-kj24ws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/468267/original/file-20220610-20-kj24ws.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/468267/original/file-20220610-20-kj24ws.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In August 2020, nursing staff staged a protest in front of Downing Street to demanding a pay rise.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-8th-august-2020-nhs-1810969111">John Gomez | Shutterstock</a></span>
</figcaption>
</figure>
<p>This divestment does not reflect either the necessity or demands of bedside nursing. It is <a href="https://www.youtube.com/watch?v=VC4FajTFpRU&ab_channel=TEDxTalks">physically and emotionally laborious</a> work, and it comes at a price. <a href="https://pubmed.ncbi.nlm.nih.gov/33434920/">Cross-workforce studies demonstrate</a> that nurses across the board are unquestionably more at risk of post-traumatic stress disorder, anxiety, depression, alcohol dependency, self-harm and suicidal thinking. </p>
<p>While research has shown a link between <a href="https://pubmed.ncbi.nlm.nih.gov/33434920/">increases in mental health disorders</a> among staff and peaks in COVID admissions, this has less to do with the <a href="https://theconversation.com/heroes-or-just-doing-our-job-the-impact-of-covid-19-on-registered-nurses-in-a-border-city-143787">trauma of COVID-specific care</a> than it does the increased adverse impacts of being overstretched and under-resourced. </p>
<p>This was most keenly felt beyond the COVID critical-care wards into which resources were pooled, something I witnessed firsthand. </p>
<h2>How rationing care causes distress to patients and staff</h2>
<p>During the first wave I was redeployed to a COVID high-dependency unit, looking after patients who were critically ill. This left me shocked, stressed and upset. But nothing prepared me for my return to a depleted and overburdened oncology ward for the second wave.</p>
<p>There, patients were neglected because we were unable to adequately meet their needs. It was there – and not on COVID wards – that I felt unsafe, that I witnessed more drug errors, longer wait times, inadequate levels of basic care and limited lifesaving interventions.</p>
<p>When need is limitless and resources are finite, patients suffer <a href="https://doi.org/10.3389/fpsyg.2021.676970">indignity, harm and neglect</a>. How bedside nurses prioritise who gets their time and attention forms the crux of my research. I have found that the process of denying care to some in order to provide to others – which experts refer to as care “<a href="https://www.kingsfund.org.uk/publications/thinking-about-rationing">rationing</a>– has a seriously detrimental effect on bedside nurses.</p>
<figure class="align-center ">
<img alt="A nurse in protective gear sits on the floor in an empty corridor." src="https://images.theconversation.com/files/468271/original/file-20220610-24020-nb7217.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/468271/original/file-20220610-24020-nb7217.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/468271/original/file-20220610-24020-nb7217.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/468271/original/file-20220610-24020-nb7217.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/468271/original/file-20220610-24020-nb7217.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/468271/original/file-20220610-24020-nb7217.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/468271/original/file-20220610-24020-nb7217.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">COVID saw nurses around the world pushed beyond their limits.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/9/9c/Covid-19_San_Salvatore_09.jpg">Alberto Giuliani/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Healthcare rationing is a <a href="https://www.euro.who.int/__data/assets/pdf_file/0007/118582/E60144.pdf">human rights issue</a> and not being able to provide good care is a significant cause of <a href="https://doi.org/10.1016/j.ijnurstu.2020.103688">distress</a>. Unlike policy and macro-level rationing, where institutions are ultimately held responsible for the effective neglect in which the rationing results, care rationing shifts the moral responsibility to the carer. </p>
<p>Nurses must <a href="https://doi.org/10.1177%2F0969733018759831">bear the burden</a> of deciding who gets fed their meals while still hot, who lies in soiled sheets and who is left to die alone. To try and mitigate these injustices, they get in early and stay late. They skip meals, they work through breaks, and they burn out. </p>
<p>I am currently working with the <a href="https://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fcovidandsociety.com%2F&data=05%7C01%7Crebecca.williams.12%40ucl.ac.uk%7Ca7bcfa9d445e4ae4f81508da4ac005ff%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C0%7C637904485830829545%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=YG%2Fm12j0wh9GtjZQJDIwW0RBUBPTENUm8mF1QVnjco0%3D&reserved=0">International Public Policy Observatory</a> on a <a href="https://www.eventbrite.co.uk/e/nhs-staff-wellbeing-what-works-and-the-case-for-investment-tickets-327333050967">rapid evidence review</a>, demonstrating how poor mental health among NHS staff is placing an overwhelming operational burden on the service. This comes at a significant financial cost.</p>
<p>While statistics on nurses’ mental wellbeing and its wider impact draw much-needed attention to the subject, surveys and reporting cannot do justice to the reality of working on an understaffed, under-resourced, and overstretched acute NHS ward. They cannot adequately convey the physical, emotional, and mental stress bedside nurses <a href="https://theconversation.com/covid-19-frontline-nurses-did-not-receive-the-mental-health-support-they-deserved-166377">endure</a>.</p>
<p>As long as the role itself continues to be devalued and as long as bedside nurses are held to an impossible standard, this will not change.</p>
<hr>
<p><em>On Friday June 17, The Conversation’s partner organisation, the <a href="https://covidandsociety.com/">International Public Policy Observatory</a>, is hosting an online event to launch its rapid evidence review on NHS staff wellbeing and mental health. Speakers will include Dr Steve Boorman CBE and Professor Dame Carol Black. Sign up <a href="https://www.eventbrite.co.uk/e/nhs-staff-wellbeing-what-works-and-the-case-for-investment-tickets-327333050967">here</a> for this free event.</em></p><img src="https://counter.theconversation.com/content/184505/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Williams' research work receives funding from The European Social Research Council and UCL Dean's Strategic Fund.</span></em></p>Nursing has long been seen as a vocation, not a skill. This impacts nursing staff and patients both.Rebecca Williams, PhD researcher in Anthropology, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1711022021-12-13T13:25:27Z2021-12-13T13:25:27ZThe US doesn’t have enough faculty to train the next generation of nurses<figure><img src="https://images.theconversation.com/files/434267/original/file-20211128-17-elh123.jpg?ixlib=rb-1.1.0&rect=0%2C11%2C7935%2C5238&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some nursing programs had to turn away students because of a shortage of faculty and clinical sites. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/nurse-attending-to-patients-needs-during-covid-19-royalty-free-image/1257336821"> FatCamera/E+ Collection via Getty Images</a></span></figcaption></figure><p>Despite a national <a href="https://theconversation.com/amid-a-raging-pandemic-the-us-faces-a-nursing-shortage-can-we-close-the-gap-149030">nursing shortage in the United States</a>, over <a href="https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/24802/2020-survey-data-student-enrollment">80,000 qualified applications were not accepted at U.S. nursing schools</a> in 2020, according to the American Association of Colleges of Nursing. </p>
<p>This was <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">due primarily</a> to a shortage of nursing professors and a limited number of clinical placements where nursing students get practical job training. <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">Additional constraints</a> include a shortage of experienced practitioners to provide supervision during clinical training, insufficient classroom space and inadequate financial resources.</p>
<p>Although the 80,000 <a href="https://www.ncsbn.org/LTL_Fall2021.pdf#page=17">may not account</a> for students who apply to multiple nursing schools, it clearly suggests that not all qualified students are able to enroll in nursing school. </p>
<p>I am a nurse researcher, <a href="https://health.usf.edu/nursing/faculty-staff/directory/raynaletourneau">professor of nursing</a> and founding director of <a href="https://health.usf.edu/nursing/partnerships/wires">WIRES</a>, an office at the University of South Florida that focuses on the well-being of the health care workforce. I’ve found that the nursing shortage is a complex issue that <a href="http://healthworkforcestudies.com/news/state_of_the_nursing_workforce_paper.pdf">involves many factors</a> – but chief among them is the shortage of faculty to train future nurses.</p>
<h2>Growing demand for nurses</h2>
<p>There are not enough new nurses entering the U.S. health care system each year to meet the country’s <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm">growing demand</a>. This can have serious consequences for <a href="https://psnet.ahrq.gov/primer/nursing-and-patient-safety">patient safety</a> and <a href="https://doi.org/10.1093/restud/rdaa082">quality of care</a>. </p>
<p>Nationally, the number of jobs for registered nurses is <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-6">projected to increase by 9% between 2020 and 2030</a>. </p>
<p>Some states project an even higher demand for registered nurses because of their population and their needs. Florida, for example, will need to <a href="https://projectionscentral.org/Projections/LongTerm?AreaName=&AreaNameSelect%5B%5D=12&Name=nurse&items_per_page=10">increase its number of registered nurses by 16%</a> over the next decade.</p>
<p>The U.S. Bureau of Labor Statistics estimates there will be about <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm">194,500 openings</a> for registered nurses each year over the next decade to meet the demands of the growing population, and also to replace nurses who retire or quit the profession. This means the U.S. will need about <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm">2 million new registered nurses</a> by 2030.</p>
<p>In addition to a shortage of registered nurses, there is also a shortage of nurse practitioners. Nurse practitioner is identified as the <a href="https://www.bls.gov/emp/images/growing_occupations.png">second fastest-growing occupation</a> in the next decade, after wind turbine technicians, with a projected increase of 52.2%. Nurse practitioners have an advanced scope of practice compared with registered nurses. They must complete additional clinical hours, earn a master’s or doctoral degree in nursing, and complete additional certifications to work with specific patient populations. </p>
<p>The COVID-19 pandemic has exacerbated the <a href="https://nursing.osu.edu/news/2021/09/23/new-study-examines-association-between-nurses-well-being-workplace-wellness">health and wellness problems of the nursing workforce</a>. Despite these problems, student enrollment in nursing schools <a href="https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/24802/2020-survey-data-student-enrollment">increased in 2020</a>. The pandemic has not turned people away from wanting to pursue a career in nursing. However, without enough nursing faculty and clinical sites, there will not be enough new nurses to meet the health care demands of the nation. </p>
<figure class="align-center ">
<img alt="Women in red scrubs hold signs encouraging people to get vaccinated" src="https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436725/original/file-20211209-23-1m60ltq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Student enrollment in nursing schools increased in 2020 amid the COVID-19 pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/indiana-university-nursing-students-hold-signs-encouraging-news-photo/1235910444">Jeremy Hogan/SOPA Images/LightRocket via Getty Images</a></span>
</figcaption>
</figure>
<h2>Need for more nursing faculty</h2>
<p>Currently, the national <a href="https://www.aacnnursing.org/Portals/42/News/Surveys-Data/2020-Faculty-Vacancy-Report.pdf">nurse faculty vacancy rate is 6.5%</a>. This is slightly improved from the <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">2019 rate of 7.2%</a>. More than half of all nursing schools <a href="https://www.aacnnursing.org/Portals/42/News/Surveys-Data/2020-Faculty-Vacancy-Report.pdf">report vacant full-time faculty positions</a>. The highest need is in nursing programs in <a href="https://www.aacnnursing.org/News-Information/News/View/ArticleId/25043/data-spotlight-august-2021-Nursing-Faculty-Shortage">Western and Southern states</a>. </p>
<p>Nursing education in clinical settings requires smaller student-to-faculty ratios than many other professions in order to maintain the safety of patients, students and faculty members. Regulatory agencies recommend at least one faculty member to <a href="https://www.ncsbn.org/ga_chapter410.pdf">no more than 10 students</a> engaged in clinical learning.</p>
<p>The faculty shortage is also affected by the fact that many current nursing faculty members are <a href="https://doi.org/10.1016/j.outlook.2017.03.003">reaching retirement age</a>. The percentage of full-time nursing faculty members <a href="https://www.nursingoutlook.org/article/S0029-6554(16)30314-1/fulltext">aged 60 and older</a> increased from roughly 18% in 2006 to nearly 31% in 2015. </p>
<p>The American Association of Colleges of Nursing reports the <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">average ages</a> of doctorally prepared nurse faculty members at the ranks of professor, associate professor and assistant professor were 62.6, 56.9 and 50.9 years, respectively.</p>
<p>[<em>More than 140,000 readers get one of The Conversation’s informative newsletters.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140K">Join the list today</a>.]</p>
<p>Another factor that contributes to the nursing faculty shortage, and the most critical issue <a href="https://www.aacnnursing.org/Portals/42/News/Surveys-Data/2020-Faculty-Vacancy-Report.pdf">related to faculty recruitment</a>, is compensation. The salary of a nurse with an advanced degree is much higher in clinical and private sectors than it is in academia. </p>
<p>According to a survey by the American Association of Nurse Practitioners, the <a href="https://www.aanp.org/about/all-about-nps/np-fact-sheet">median salary of a nurse practitioner</a>, across settings and specialties, is $110,000. By contrast, the AACN reported in March 2020 that the <a href="https://www.aacnnursing.org/news-information/fact-sheets/nursing-faculty-shortage">average salary for master’s-prepared assistant professors</a> in nursing schools was just under $80,000. </p>
<figure class="align-center ">
<img alt="Two people wearing face masks and scrubs fill a syringe" src="https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=442&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=442&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=442&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=556&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=556&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436726/original/file-20211209-104971-1unb5cz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=556&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A registered nurse, at right, helps a nursing student prepare a dose of the COVID-19 vaccine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/western-university-of-health-sciences-master-nursing-news-photo/1300409969">Will Lester/MediaNews Group/Inland Valley Daily Bulletin via Getty Images</a></span>
</figcaption>
</figure>
<h2>Fixing the faculty shortage</h2>
<p>Innovative strategies are needed to address the nursing faculty shortage. The <a href="https://www.congress.gov/bill/116th-congress/house-bill/728">Title VIII Nursing Workforce Reauthorization Act of 2019</a> was a start. The act provides funding for nursing faculty development, scholarships and loan repayment for nurses, and grants for advanced nursing education, nursing diversity initiatives and other priorities.</p>
<p>The Build Back Better Act that <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376">passed the U.S. House of Representatives</a> in November 2021 includes funding to help nursing schools across the country recruit and retain diverse nursing faculty and enroll and retain nursing students. The act is now before the U.S. Senate.</p>
<p>In addition to national strategies, individual states are addressing the shortage at the local level. Maryland, for example, awarded over <a href="https://mhec.maryland.gov/Pages/6-3-20.aspx">$29 million in grants</a> to 14 higher education institutions with nursing programs in Maryland to expand and increase the number of qualified nurses.</p>
<p>Finally, offering faculty salaries comparable to those in clinical settings may attract more nurses to use their expertise to train and expand the next generation of health care workers.</p><img src="https://counter.theconversation.com/content/171102/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rayna M. Letourneau receives funding from philanthropic supporters to build programs to recruit and retain competent nurses and nursing students into the profession. </span></em></p>The US has a growing demand for nurses. Yet nursing schools are turning away many qualified candidates.Rayna M. Letourneau, Assistant Professor of Nursing, University of South FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1663252021-09-17T12:19:57Z2021-09-17T12:19:57ZNurses are leaving the profession, and replacing them won’t be easy<figure><img src="https://images.theconversation.com/files/420102/original/file-20210908-21-1czjthe.jpg?ixlib=rb-1.1.0&rect=60%2C0%2C6720%2C4466&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many nurses are physically and emotionally exhausted from the toll of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/male-nurse-struggles-with-mental-health-royalty-free-image/1309350765">lightspeedshutter/iStock via Getty Images Plus</a></span></figcaption></figure><p>The fourth wave of COVID-19 is exacerbating the <a href="https://www.usnews.com/news/health-news/articles/2021-08-19/fourth-covid-wave-swamps-stressed-nurse-corps">ongoing crisis for the nursing workforce</a> and has <a href="https://www.turnto23.com/news/national/coronavirus/you-dont-necessarily-feel-heroic-anymore-health-care-workers-facing-burnout-amid-4th-covid-wave">led to burnout</a> for many nurses. As a result, <a href="https://www.opb.org/article/2021/07/21/working-conditions-understaffing-is-driving-nurses-to-quit/">many are quitting</a> their jobs in substantial numbers <a href="https://www.npr.org/2021/08/10/1026577164/hospitals-face-a-shortage-of-nurses-as-covid-cases-soar">all across the country</a>, with 62% of hospitals reporting <a href="https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf">a nurse vacancy rate higher than 7.5%</a>, according to a 2021 NSI Nursing Solutions report.</p>
<p>But the global pandemic has only worsened problems that have long existed within the nursing profession – in particular, widespread <a href="https://www.everydayhealth.com/news/why-americas-nurses-are-burning-out/">stress</a> and <a href="https://nurse.org/articles/risks-for-nurse-burnout-symptoms/">burnout</a>, <a href="https://www.nursingworld.org/practice-policy/work-environment/health-safety/health-safety-survey/">health and safety issues</a>, <a href="https://www.fiercehealthcare.com/healthcare/depression-a-silent-epidemic-for-nurses">depression</a> and <a href="https://doi.org/10.1111/jocn.15288">work-related post-traumatic stress disorder</a>, and even <a href="https://www.nursingworld.org/practice-policy/nurse-suicide-prevention/">increased risk of suicide</a>. </p>
<p>In addition, nurses need to contend with <a href="https://www.amihm.org/nurse-workload-staffing-and-measurement/">growing workloads</a> and <a href="https://www.nursingworld.org/practice-policy/nurse-staffing/">inadequate staffing</a>, or not having the right number of nurses on the right units to ensure that patients receive safe quality care. <a href="https://onlinedegrees.bradley.edu/blog/mandatory-overtime-what-you-need-to-know/">Mandatory overtime</a> is another challenge and occurs when nurses must work extra hours beyond their shift because of staffing shortages. All of these issues can lead to low job satisfaction among nurses and are likely to contribute to nurses’ <a href="https://doi.org/10.1016/j.apnr.2019.06.001">leaving the profession</a>, a trend that began well before the current pandemic struck. </p>
<p>Despite more awareness of the challenges nurses currently face, <a href="https://doi.org/10.1056/NEJMsa1001025">nurse staffing and its impact on patient safety</a> have been studied for more than 20 years. My role as a <a href="https://health.usf.edu/nursing/faculty-staff/directory/raynaletourneau">nurse researcher and assistant professor</a> at the University of South Florida is to evaluate the needs of the nursing workforce and <a href="https://health.usf.edu/nursing/frontline-nursing">design and implement programs</a> to address them. </p>
<p>Here’s why the pandemic has made the nursing shortage even worse, and why I think health care leaders need to make bold changes to address the well-being of nurses – for the sake of nurses and patient care in our country. </p>
<h2>Disruptions in health care delivery</h2>
<p>Nurses, like many health care workers, are <a href="https://doi.org/10.1001/jamanetworkopen.2020.36469">physically and emotionally exhausted</a> after working in what has been <a href="https://www.nytimes.com/2021/08/21/health/covid-nursing-shortage-delta.html">described as a “war zone”</a> for the better part of the past year and a half. One nurse on the front lines reported <a href="https://twitter.com/shesinscrubs/status/1432796040684523523">irreversible damage</a> from the trauma of caring for extremely sick patients. Others are experiencing shortages of <a href="https://www.advisory.com/daily-briefing/2021/09/01/oxygen-shortage">oxygen,</a> equipment and <a href="https://hbr.org/2020/09/why-the-u-s-still-has-a-severe-shortage-of-medical-supplies">other needed supplies</a> to keep themselves safe and to keep their patients alive. </p>
<p>As more nurses leave the workforce, patient care will no doubt suffer. Research has shown a relationship between <a href="https://doi.org/10.1001/jama.288.16.1987">nurse staffing ratios and patient safety</a>. <a href="https://www.ncbi.nlm.nih.gov/books/NBK2657/">Increased workload</a> and stress can put nurses in situations that are more likely to lead to <a href="https://www.ncbi.nlm.nih.gov/books/NBK430763/">medical errors</a>. Lower nurse staffing and higher patient loads per nurse are associated with an <a href="https://doi.org/10.1136/bmjqs-2018-008043">increased risk for patients of dying</a> in the hospital. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1432796040684523523"}"></div></p>
<p>Because <a href="https://www.nytimes.com/2021/08/21/health/covid-nursing-shortage-delta.amp.html">hospitals cannot open beds</a> if there are no nurses to staff them, some hospitals are being forced to <a href="https://www.wfaa.com/article/news/health/coronavirus/some-north-texas-hospitals-close-ers-shift-staff-to-address-covid-19-patient-surge/287-3692c51d-00b1-4825-8fb3-343e239ef56e">shut down emergency rooms</a> and <a href="https://abc7news.com/coronavirus-surge-4th-wave-nurse-shortage/10922472/">turn away patients in need of medical care</a>. That is a problem for not only hospitals in large cities; <a href="https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2021/09/01/rural-hospitals-cant-find-the-nurses-they-need-to-fight-covid">rural hospitals</a> are also struggling. Alarmingly, some hospitals are considering the <a href="https://www.npr.org/sections/health-shots/2021/09/05/1034210487/covid-surge-overwhelming-hospitals-raising-fears-rationed-care">need to potentially ration medical care</a>. </p>
<h2>How some hospitals are addressing the shortage</h2>
<p>Hospitals are desperate to fill nursing vacancies. One hospital system in South Dakota is offering incentives as large as <a href="https://www.beckershospitalreview.com/compensation-issues/south-dakota-health-system-offers-40k-signing-bonus-to-nurses.html">US$40,000 sign-on bonuses</a> to recruit nurses to work in the clinical areas that are in most need. This may be a great attempt to draw nurses to an institution, but sign-on bonuses and <a href="https://www.vox.com/22600439/nurse-america-mental-health-suicide">incentives might not be enough</a> to persuade some nurses to work at the bedside and continue contending with the current workload of the pandemic. </p>
<p>Another strategy to fill vacancies is the use of travel nurses. Travel nurses work for agencies that assign them to hospitals that cannot fill vacancies with their own staff. Although this can be a successful short-term solution, the use of travel nurses is not sustainable over time and it does not help retain experienced staff nurses in an organization. Travel nurses make <a href="https://www.travelnursing.org/why-travel-nurses-make-more-money/">significantly more money</a> than staff nurses, which may lure nurses away from permanent positions and in turn increase the staffing deficit for hospitals. The <a href="https://www.indeed.com/career/travel-nurse/salaries">average salary</a> for a travel nurse in the U.S. is $2,003 per week, with $13,750 in overtime per year. Some nurses even accept <a href="https://cronkitenews.azpbs.org/2021/04/28/travel-nurses-staffing-industry-pushed-to-the-limits-by-covid/">“crisis assignments,”</a> which can pay as much as $10,000 per week. That is significantly higher than the average of $1,450 per week (<a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-1">$36.22 per hour</a>) for a staff nurse.</p>
<figure class="align-center ">
<img alt="masked female health care worker looking straight at camera with arms crossed" src="https://images.theconversation.com/files/420103/original/file-20210908-15-482jxf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420103/original/file-20210908-15-482jxf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420103/original/file-20210908-15-482jxf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420103/original/file-20210908-15-482jxf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420103/original/file-20210908-15-482jxf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420103/original/file-20210908-15-482jxf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420103/original/file-20210908-15-482jxf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hospitals cannot open beds if there are no nurses to staff them.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/african-american-doctor-nurse-with-arms-crossed-royalty-free-image/1272765461">Morsa Images/DigitalVision via Getty Images</a></span>
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<h2>Focus on nurses’ well-being</h2>
<p>For the past 18 years, nursing has been identified as the <a href="https://news.gallup.com/poll/274673/nurses-continue-rate-highest-honesty-ethics.aspx">most trusted profession</a>. Nurses are caregivers, role models, educators, mentors and advocates and have a direct impact on the health and well-being of patients. The health of the nation’s nursing workforce is fundamental to our health care industry. As identified by a 2021 <a href="https://nam.edu/publications/the-future-of-nursing-2020-2030/">National Academy of Medicine report</a>, nurse well-being and resilience are needed to ensure the delivery of high-quality care and to improve the health of the nation.</p>
<p><a href="https://ppc.sas.upenn.edu/learn-more/perma-theory-well-being-and-perma-workshops">Research demonstrates</a> that people with higher levels of well-being have lower levels of burnout and perform better at work. Therefore, some hospitals and unions are offering <a href="https://www.nationalnursesunited.org/national-covid-19-mental-health-resources">resources and programs</a> to nurses during the COVID-19 pandemic that seek to <a href="https://www.nursingworld.org/practice-policy/work-environment/health-safety/combating-stress/">reduce stress</a>, <a href="https://degree.astate.edu/articles/nursing/resilience-is-important-for-nurses.aspx">promote resiliency</a> and <a href="https://www.mywellbeingindex.org/blog/7-ways-to-improve-well-being-among-nurses">increase well-being</a>. We have yet to see the long-term effectiveness of these programs on the health and wellness of nurses. </p>
<p>While nurses are responsible for prioritizing self-care, health care organizations are <a href="https://nam.edu/publications/the-future-of-nursing-2020-2030/">responsible for creating a workplace environment</a> in which nurses can flourish. <a href="https://www.aacn.org/newsroom/well-being-work-environment-affect-medical-errors">Nurses report fewer medical errors</a> when their well-being is supported by their organizations and they are in better physical and mental health.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1437836802631643145"}"></div></p>
<p>The long-term solution to the nursing shortage calls for <a href="https://www.aacnnursing.org/News-Information/Position-Statements-White-Papers/Reverse-Shortage">systematic changes</a> that value nurses and offer them a safe place to work. Examples include implementing appropriate salaries and flexible schedules, ensuring adequate nurse staffing, and creating jobs that allow aging nurses to continue working in direct patient care roles so they can remain in the workforce longer instead of retiring. The pandemic has made more people aware of the distressing conditions many nurses work in. But without systematic changes, the drain of nurses out of the profession – and its negative impact on patient care – will only continue.</p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p><img src="https://counter.theconversation.com/content/166325/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rayna M. Letourneau does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Long-term solutions to the nursing shortage call for changes that value nurses and offer them a safe place to work.Rayna M. Letourneau, Assistant Professor of Nursing, University of South FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1664762021-08-29T10:55:28Z2021-08-29T10:55:28ZHigh rates of COVID-19 burnout could lead to shortage of health-care workers<figure><img src="https://images.theconversation.com/files/417664/original/file-20210824-16663-1mz17j6.png?ixlib=rb-1.1.0&rect=0%2C9%2C1235%2C903&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Intensive care nurse Kathryn Ivey's Tweet illustrates the impact of the pandemic on health-care workers. Used with permission.</span> <span class="attribution"><a class="source" href="https://twitter.com/kathryniveyy/status/1330607852524867587">@kathryniveyy/Twitter</a>, <span class="license">Author provided</span></span></figcaption></figure><p>During the pandemic’s third wave, researchers interviewed nurses to see how their <a href="https://windsor.ctvnews.ca/tired-burned-out-and-angry-uwindsor-study-sheds-light-on-state-of-working-nurses-1.5536147">perceptions had changed over the preceding year</a>. Early in the pandemic, nurses had reported optimism about supporting one another through the pandemic, but by the third wave, this had been replaced by anger and exhaustion. </p>
<p>One source of resentment was how employers were managing a depleted workforce. Clinical psychologist Dana Ménard found that incentives for new hires caused anger among those who had been on the front lines for a year with no retention rewards. Vicki McKenna, president of the Ontario Nurses Association, expressed concerns about staffing, <a href="https://windsorstar.com/news/local-news/tired-depressed-angry-nurses-leaving-jobs-during-pandemic-windsor-study-finds">telling a reporter</a>, “I fear that it is going to be devastating to the workforce. I’m very worried about the future of the nursing workforce.”</p>
<p>Meanwhile, other sources warned of a potential shortage of nurses. “Canadian nurses are leaving in droves,” <a href="https://www.theglobeandmail.com/canada/article-canadian-nurses-are-leaving-in-droves-worn-down-by-16-merciless-months/">ran a <em>Globe and Mail</em> headline</a>.</p>
<h2>Understanding burnout</h2>
<p>Appreciating what is happening to these nurses and how to respond hinges on understanding burnout, which may be the primary occupational hazard of health-care work. This is especially true in a pandemic. <a href="https://doi.org/10.1186/s12960-020-00469-9">Burnout, as it is typically measured, has three components</a>: emotional exhaustion, depersonalization (indifference or emotional distance) and a diminished sense of professional achievement. </p>
<p>Burnout occurs in many occupations, but health care exposes its professionals to unusual types of stress, <a href="https://doi.org/10.1177/0969733020909523">including moral distress</a>. This arises when professionals feel constrained from providing the best care. Examples include situations when care may be too aggressive at the end of life, or when one health-care worker is concerned about care provided by another. Moral distress has increased during the pandemic <a href="https://doi.org/10.1097/ccm.0000000000004865">due to scarce resources</a> and the <a href="https://doi.org/10.1186/s12913-021-06555-5">inability to comfort families</a>.</p>
<h2>Consequences of burnout</h2>
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<a href="https://images.theconversation.com/files/417915/original/file-20210825-21-y456gx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Nurses close the curtains of a patients room in the COVID-19 Intensive Care Unit at Surrey Memorial Hospital in Surrey, B.C." src="https://images.theconversation.com/files/417915/original/file-20210825-21-y456gx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417915/original/file-20210825-21-y456gx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417915/original/file-20210825-21-y456gx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417915/original/file-20210825-21-y456gx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417915/original/file-20210825-21-y456gx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417915/original/file-20210825-21-y456gx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417915/original/file-20210825-21-y456gx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Burnout occurs in many occupations, but health care exposes its professionals to unusual types of stress.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
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<p>Burnout is bad for everyone. It is associated with <a href="https://doi.org/10.1186/s12960-020-00469-9">diminished safety and quality of care for patients</a>, and <a href="https://doi.org/10.1111/joim.12752">mental health problems and poor quality of life for professionals</a>. </p>
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Read more:
<a href="https://theconversation.com/heroes-or-just-doing-our-job-the-impact-of-covid-19-on-registered-nurses-in-a-border-city-143787">Heroes, or just doing our job? The impact of COVID-19 on registered nurses in a border city</a>
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<p>For the health-care system, burnout is associated with <a href="https://doi.org/10.1186/s12960-020-00469-9">absenteeism, reduced productivity and thoughts of leaving one’s job</a>. During a time <a href="https://www.cbc.ca/radio/thecurrent/the-current-for-feb-22-2021-1.5922712/canada-is-facing-a-nursing-shortage-here-s-why-it-s-hard-to-fill-the-gap-1.5923251">when nurses</a> and <a href="https://www.fraserinstitute.org/sites/default/files/supply-of-physicians-in-canada.pdf">doctors are in short supply</a>, we cannot afford to lose more because of burnout.</p>
<h2>Burnout is rising</h2>
<p>Burnout was common before COVID-19 and is now rampant. For example, rates of severe emotional exhaustion were <a href="https://doi.org/10.1001/jama.2018.12777">often in the range of 20 to 40 per cent</a> prior to the pandemic, with higher rates in intensive care units and emergency medicine. Compare that to Canadian surveys later in the pandemic reporting <a href="https://doi.org/10.1016/j.genhosppsych.2021.04.012">rates of 62 per cent</a>, <a href="https://doi.org/10.1136/bmjopen-2021-050380">63 per cent</a> and <a href="https://www.oma.org/newsroom/news/2021/aug/ontarios-doctors-report-increased-burnout-propose-five-solutions/">72 per cent</a>.</p>
<p>It should be no surprise that working in health care during a pandemic that is unprecedented in our lifetimes has increased burnout. </p>
<p>In addition to risking their own health, many health-care professionals have been, for example, working longer hours and are often understaffed if colleagues are in quarantine or ill. Many maintained their full-time job while their children were unable to attend school. They must also manage uncertainty as policies change and a virus mutates, while providing care to critically ill individuals who chose not to be vaccinated.</p>
<h2>Burnout may deplete the health-care workforce</h2>
<p>Surveys of health-care workers reveal an extraordinary challenge. <a href="https://rnao.ca/sites/rnao-ca/files/Nurses_Wellbeing_Survey_Results_-_March_31.pdf">A survey of members of the Registered Nurses Association of Ontario</a> found 43 per cent were considering leaving, more among those who felt burnt out. Another Canadian study reported <a href="https://doi.org/10.1097/ceh.0000000000000365">50 per cent of nurses surveyed</a> intended to leave.</p>
<p><a href="https://ottawacitizen.com/news/local-news/signing-bonuses-are-a-sign-of-the-times-as-desperate-hospitals-seek-nurses">Signing bonuses for new nurses</a>, which angered the nurses Dr. Ménard’s team interviewed, suggest that the intention to leave is translating into action. Indeed, <a href="https://www.cbc.ca/news/canada/british-columbia/nurses-quitting-kamloops-interior-health-1.6148410">reports of shortages related to pandemic burnout</a> continue to appear in the news.</p>
<p>Since understaffing is both a cause and consequence of burnout, the health-care system may be entering the downward spiral of a particularly vicious circle. </p>
<h2>Solutions</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/417918/original/file-20210825-18784-natref.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman walks by a street mural of a health-care worker in protective equipment, flexing her bicep" src="https://images.theconversation.com/files/417918/original/file-20210825-18784-natref.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/417918/original/file-20210825-18784-natref.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=789&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417918/original/file-20210825-18784-natref.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=789&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417918/original/file-20210825-18784-natref.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=789&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417918/original/file-20210825-18784-natref.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=992&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417918/original/file-20210825-18784-natref.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=992&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417918/original/file-20210825-18784-natref.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=992&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Instead of optimism about supporting one another, nurses are now reporting anger and exhaustion.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
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<p>The solution should match the problem. Evidence indicates that <a href="https://doi.org/10.1111/joim.12752">burnout is more a consequence of work conditions than of the workers’ vulnerabilities</a>: of long hours, high workload, moral distress and <a href="https://doi.org/10.3390/healthcare8020098">violence and abuse in the workplace</a>, among other systemic problems. </p>
<p>And yet, most research studying interventions to prevent and reduce burnout focuses instead on individuals by teaching things like coping skills and stress reduction techniques. Although providing individual interventions <a href="https://doi.org/10.1016/S0140-6736(16)31279-X">may be moderately helpful</a>, as the sole response to an occupational hazard, it is perverse — like teaching the residents of a flood zone how to swim instead of elevating their homes or helping them to move. </p>
<p>The health-care system urgently needs <a href="https://doi.org/10.1111/joim.12752">system-level measures</a> that protect its professionals from harm, and compensate them for hazards. These may include manageable hours, adequate time off, appropriate staff-to-patient ratios and <a href="https://www.patientsafetyinstitute.ca/en/toolsResources/Creating-a-Safe-Space-Psychological-Safety-of-Healthcare-Workers/Pages/creating-a-safe-space-addressing-the-psychological-safety-of-healthcare-workers-2020-01-06.aspx">workplace safety measures</a>. Some organizations will try to recruit new health professionals to manage shortages, but recruitment into a harmful environment is not sustainable. </p>
<p>Which brings us to leadership. <a href="https://doi.org/10.1016/j.mayocp.2019.10.041">Evidence supports the value of leadership in reducing burnout in health care</a>, especially leaders <a href="https://doi.org/10.1186/s12960-020-00469-9">who are transparent, ethical, respectful, reflective and informed</a>. We need health-care leaders who are <a href="https://doi.org/10.1016/j.mayocp.2016.10.004">committed to protecting the health of providers and organizations</a> as well as patients. System level support is needed to prevent the COVID-19 pandemic from causing an exodus of professionals from health care.</p><img src="https://counter.theconversation.com/content/166476/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Maunder receives funding from the Canadian Institutes of Health Research and is a member of the Mental Health Working Group of the Ontario COVID-19 Science Advisory Table.</span></em></p><p class="fine-print"><em><span>Gillian Strudwick receives funding from the Canadian Institutes of Health Research and is a member of the Mental Health Working Group of the Ontario COVID-19 Science Advisory Table. She also works at the Centre for Addiction and Mental Health.</span></em></p>Rates of burnout have increased alarmingly among health-care workers during the pandemic. Unless the system provides more support to its already depleted workforce, staff shortages may get worse.Robert Maunder, Professor of Psychiatry, University of TorontoGillian Strudwick, Scientist and Assistant Professor, Institute of Health Policy, Management and Evaluation, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1659662021-08-24T04:46:00Z2021-08-24T04:46:00ZWe’re seeing more COVID patients in ICU as case numbers rise. That affects the whole hospital<p>Rising COVID cases in several Australian states means demand for intensive care unit (ICU) beds and specialist critical nurses will rise.</p>
<p>This <a href="https://www.theaustralian.com.au/nation/intensive-care-bed-shortage-fears-as-admissions-spike/news-story/3c6f9de4094265fb7fdc3cb9f94c2756">increase in demand</a> is on top of the typical workload ICUs might see.</p>
<p>And because of the nature of COVID itself and other factors, this puts pressure on the entire hospital system.</p>
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Read more:
<a href="https://theconversation.com/how-are-the-most-serious-covid-19-cases-treated-and-does-the-coronavirus-cause-lasting-damage-134398">How are the most serious COVID-19 cases treated, and does the coronavirus cause lasting damage?</a>
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<h2>What happens in ICU?</h2>
<p>The ICU is where we care for the most critically unwell patients, where treatments are designed to support breathing and circulatory problems affecting the heart, blood, or blood vessels. </p>
<p>The most unstable and sickest ICU patients require airway support in the form ventilation to help them breathe. They also need circulatory support in the form of drugs to improve blood pressure and heart function.</p>
<p>Patients come to ICU as a planned admission (for example, after a complex operation), or as an emergency admission (for example, after a serious car accident). </p>
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Read more:
<a href="https://theconversation.com/icu-ventilators-what-they-are-how-they-work-and-why-its-hard-to-make-more-135423">ICU ventilators: what they are, how they work and why it's hard to make more</a>
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<p>Patients stay for, on average, <a href="https://journals.lww.com/healthcaremanagerjournal/Abstract/2014/04000/Reduction_of_Intensive_Care_Unit_Length_of_Stay_.5.aspx">three days</a> in ICU before recovering enough to be moved to a ward, or sadly, dying. </p>
<p>Because patients in ICU are <a href="https://journals.lww.com/healthcaremanagerjournal/Fulltext/2020/07000/Reduction_of_Intensive_Care_Unit_Length_of_Stay_.1.aspx">unstable and critically unwell</a>, there is usually one nurse to care for each patient. This is a highly skilled job. Most ICU nurses have <a href="https://www.sciencedirect.com/science/article/pii/S1036731418300158">extra postgraduate qualifications</a>.</p>
<h2>COVID changed the type of patients we see</h2>
<p>Patients who are <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30161-2/fulltext">critically ill with COVID</a> are <a href="https://www.mja.com.au/journal/2021/214/1/outcomes-patients-covid-19-admitted-australian-intensive-care-units-during-first">often sicker</a> than other ICU patients and may require more support for their breathing and circulation. Often, they need to stay in ICU longer than other patients. </p>
<p>This creates challenges for hospital systems, because beds in ICU become blocked, and planned operations <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-06371-6">may be cancelled</a> because of the <a href="https://pubmed.ncbi.nlm.nih.gov/33325070/">lack of ICU beds</a>.</p>
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<p>Once patients with COVID no longer need ventilation or circulatory support, they are transferred to the ward for additional care. They may have experienced painful procedures and have a degree of physical impairment. </p>
<p>They may also have witnessed a number of stressful events in the ICU, such as emergency resuscitation procedures and deaths, which may <a href="https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-020-00689-1">increase the risk of</a> post-traumatic stress disorder, anxiety, and depression. </p>
<p>Although we don’t have definitive long-term data, patients who have been critically ill from COVID often have a <a href="https://jamanetwork.com/journals/jama/fullarticle/2769290">long and difficult journey of recovery</a> and will likely remain dependant on health care services for some time.</p>
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Read more:
<a href="https://theconversation.com/younger-adults-can-get-very-sick-and-die-from-covid-too-heres-what-the-data-tell-us-165250">Younger adults can get very sick and die from COVID too. Here's what the data tell us</a>
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<h2>COVID changed how we nurse</h2>
<p>ICU staff looking after COVID patients have the additional demands of working in full personal protection equipment (PPE), which can be hot and uncomfortable and very challenging to work in. </p>
<p>The need to use PPE correctly, and the constant concern about becoming infected or dying if there’s an infection breach, adds to nurses ongoing stress.</p>
<p>The International Council of Nurses’ <a href="https://www.icn.ch/news/covid-19-effect-worlds-nurses-facing-mass-trauma-immediate-danger-profession-and-future-our">latest analysis</a> shows the number of nurses who have died after contracting COVID-19 globally is greater than 2,200 – more than any other health-care worker. This data are from earlier this year, so we expect those figures to have risen since then. </p>
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Read more:
<a href="https://theconversation.com/heres-the-proof-we-need-many-more-health-workers-than-we-ever-thought-are-catching-covid-19-on-the-job-145092">Here's the proof we need. Many more health workers than we ever thought are catching COVID-19 on the job</a>
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<h2>COVID challenges Australia</h2>
<p>In Australia, there has been more time to respond to the challenges of COVID. In many states, the numbers of ventilators increased, models of care were developed for COVID-positive patients, and snap lockdowns ensured scarce ICU resources were not overwhelmed.</p>
<p>However, the increasing number of positive cases in New South Wales in particular, coupled with the highly infectious Delta variant, means ICUs risk reaching capacity.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1429628240042229760"}"></div></p>
<p>At the time of writing, <a href="https://twitter.com/covid_australia/status/1429634615711391744?s=21">109 patients were in Australian ICUs</a> and 37 of these patients required ventilation.</p>
<p>Australia has <a href="https://www.mja.com.au/journal/2020/surge-capacity-australian-intensive-care-units-associated-covid-19-admissions">191 ICUs with 2,378 beds</a> and the <a href="https://www.mja.com.au/journal/2020/surge-capacity-australian-intensive-care-units-associated-covid-19-admissions">capacity</a> to increase this by by up to 4,258 beds.
But there may not be enough specialised nurses or equipment match this bed increase. </p>
<p>Surge capacity also <a href="https://www.mja.com.au/journal/2020/surge-capacity-australian-intensive-care-units-associated-covid-19-admissions">varies between ICU categories and jurisdictions</a>, with tertiary hospitals reporting more capacity. So deteriorating patients may need to be air-lifted to major metropolitan or regional centres.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/does-anyone-know-what-your-wishes-are-if-youre-sick-and-dying-from-coronavirus-135547">Does anyone know what your wishes are if you're sick and dying from coronavirus?</a>
</strong>
</em>
</p>
<hr>
<h2>What can happen in the future?</h2>
<p>Fortunately, public health measures have meant Australia has been spared the horrors of countries that were unable to successfully increase their ICU resources to meet demands, for example, Spain, Italy and the United Kingdom.</p>
<p>Yet, hospitals are still feeling the impact of a rise in critically unwell COVID patients in many ways, and will do so in the future.</p>
<p>Undergraduate student nursing placements, for example, have been delayed and many universities have moved their education online. So student nurses <a href="https://doi.org/10.1111/jan.14892">may struggle</a> to achieve the clinical hours required to graduate. This may mean a shortfall of clinically competent and educated ICU nurses in the future.</p>
<h2>The best we can do</h2>
<p>So the next time you hear the latest number of COVID patients in ICU, think of what’s behind those numbers and what this means for the whole hospital system and its staff.</p>
<p>Protect them, yourself and others by sticking to the public health advice, including getting tested with the mildest of symptoms. Most importantly, get vaccinated. People fully vaccinated against COVID rarely end up in ICU.</p><img src="https://counter.theconversation.com/content/165966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deb Massey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>COVID patients in ICU are younger, sicker and stay for longer than other critically unwell patients, affecting the entire hospital and its staff.Deb Massey, Associate Professor, Chair of Nursing, Faculty of Health, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1602392021-06-02T12:26:53Z2021-06-02T12:26:53ZSchool nurses have a big job – is 1 for every 750 kids really enough?<figure><img src="https://images.theconversation.com/files/402993/original/file-20210526-19-1krra9u.jpg?ixlib=rb-1.1.0&rect=7%2C0%2C2452%2C1637&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many school nurses are taking on even more responsibilities amid the COVID-19 pandemic.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/lansdowne-pa-may-6-shane-figueroa-16-gets-his-pfizer-news-photo/1316805602">Pete Bannan/MediaNews Group/Daily Times via Getty Images</a></span></figcaption></figure><p>When many people think of a school nurse, they imagine a person who hands out Band-Aids for boo-boos. </p>
<p>But school nurses do so much more. They are school leaders who address the physical, mental and emotional health needs of students.</p>
<p>As the COVID-19 pandemic played out, many school nurses took on even greater responsibilities. These include monitoring and evaluating staff and students for COVID-19 exposure and symptoms, <a href="https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/school-nurses-hcp.html#">contact tracing</a> and educating students, staff and community partners on vaccine and prevention measures. School nurses are also developing initiatives to deal with the anticipated <a href="https://doi.org/10.1001/jamapediatrics.2020.1456">increase in mental health services</a> that students, families and staff will need in the post-pandemic world. </p>
<p>And yet, the <a href="https://www.healthypeople.gov/node/4258/data_details">U.S. Department of Health and Human Services</a> and the <a href="https://www.cdc.gov/healthyschools/professional_development/e-learning/shg/page13.html#">Centers for Disease Control and Prevention</a> recommend that public elementary, middle and high schools aim to have one school nurse for every 750 students.</p>
<p>As a former school nurse and current <a href="https://scholar.google.com/citations?user=FVTqReEAAAAJ&hl=en">nurse scientist</a> and <a href="https://www.shu.edu/profiles/BethJameson.cfm">professor of nursing</a>, I know that this one-size-fits-all model does not consider the full role and responsibilities of the school nurse. </p>
<p>What’s more, as far as I can tell, <a href="https://doi.org/10.1177/1942602X15596582">no published research or evidence</a> supports this ratio. <a href="https://doi.org/10.1177/1942602X15596582">It’s been traced</a> at least as far back as the early 1970s and the Education for All Handicapped Children Act of 1975, now known as the <a href="https://sites.ed.gov/idea/">Individuals with Disabilities Education Act</a>.</p>
<h2>Safety net for vulnerable kids</h2>
<p>School nursing is a specialized practice that operates in environments very different from an acute care hospital setting. School nurses work alone, practice independently and are typically the sole health care provider in the building. </p>
<p>As <a href="https://doi.org/10.1542/peds.2016-0852">part of our public health system</a>, they play a critical role in disease surveillance, disaster preparedness, wellness and chronic disease prevention interventions, immunizations, mental health screening and asthma education. </p>
<p>And they are a <a href="https://doi.org/10.1016/j.outlook.2017.11.002">safety net for society’s most vulnerable children</a>. For example, if a student is experiencing food insecurity, the school nurse might <a href="https://www.nj.com/news/2019/12/backpack-program-feeds-100-students-across-12-hunterdon-schools.html">coordinate with a community partner</a> or school social worker to help the student and their family not go hungry.</p>
<p>Most school nurses will tell you they are unable to carry out many of these functions, often due to <a href="https://doi.org/10.1016/j.outlook.2017.12.002">huge workloads</a> or <a href="https://cdn2.hubspot.net/hubfs/4850206/PNS3E_ePDF.pdf">poor staffing</a>. </p>
<p>I know from personal experience. From 2009 to 2014, I was the sole school nurse responsible for the health and safety of over 900 public elementary school children. This included special education classrooms for preschoolers and students with nonverbal autism. <a href="https://scholar.google.com/citations?user=FVTqReEAAAAJ&hl=en">I now research</a> how school health policies and practices effect the work environment of school nurses, and the <a href="https://doi.org/10.1177/1942602X20913908">challenges and barriers they face</a>. </p>
<p><a href="https://doi.org/10.1177/1059840514540940">Research shows</a> how a positive work environment for school nurses increases job satisfaction, reduces turnover and <a href="https://doi.org/10.1111/j.1746-1561.2011.00632.x">improves academic outcomes</a> for students. A study of school nurses in Massachusetts schools demonstrated that for every dollar invested in school nursing, <a href="https://doi.org/10.1001/jamapediatrics.2013.5441">society would gain US$2.20</a> as a result of kids’ better health and disease prevention. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/403409/original/file-20210528-24-x7d7wo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A school nurse takes a young student's temperature" src="https://images.theconversation.com/files/403409/original/file-20210528-24-x7d7wo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/403409/original/file-20210528-24-x7d7wo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/403409/original/file-20210528-24-x7d7wo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/403409/original/file-20210528-24-x7d7wo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/403409/original/file-20210528-24-x7d7wo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/403409/original/file-20210528-24-x7d7wo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/403409/original/file-20210528-24-x7d7wo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">School nurses typically serve hundreds of students.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/school-nurse-sandra-faucette-takes-students-temperatures-as-news-photo/1231609212">Evelyn Hockstein/The Washington Post via Getty Images</a></span>
</figcaption>
</figure>
<h2>No one-size-fits-all ratio</h2>
<p>A <a href="https://doi.org/10.1177/1059840517718063">school nurse’s workload</a> depends on a number of <a href="https://doi.org/10.1177/1059840520946833">significant variables</a>. For example, how many students in the school have chronic illnesses and need medication administered? How many students attend the school? What ages are they? What is the average number of student visits to the health office each school day? Are students spread across multiple buildings? What level of experience and specialized skills does the school nurse have? </p>
<p>The number of students in a school who are dealing with poverty or other <a href="https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html">health equity issues</a> – including access to quality education, safe housing and health care – also impacts and increases the workload for school nurses. </p>
<p>These evidence-based variables can be used to guide school administrators and school nurses on what constitutes safe staffing. Making sure school nurses have a safe, appropriate workload is critical to ensuring that students have their health needs met at school. </p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p>
<p>Parents who are concerned about their child’s health at school may want to find out how many students their child’s school nurse cares for. How many students does the school nurse see on a typical day? Is a school nurse in the building every day? Does the school nurse cover more than one building? What happens when there is an emergency, such as a child with a life-threatening allergic reaction? Where are the emergency care plans kept? Is there stock medication available such as epinephrine and albuterol for students with severe allergies or asthma? </p>
<p>I believe school nurses need more manageable workloads in order to provide the safe care needed for better student health and academic outcomes. This leads to better health not just in individuals but in communities that need it most.</p><img src="https://counter.theconversation.com/content/160239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Beth Jameson receives funding from the National Association of School Nurses. She is affiliated with the National Association of School Nurses as a member. </span></em></p>A school nurse’s caseload can vary dramatically based on a school’s size and the number of students dealing with chronic disease, poverty, housing insecurity and many other concerns.Beth Jameson, Assistant Professor of Nursing, Seton Hall UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1608502021-05-27T17:02:38Z2021-05-27T17:02:38ZHow to respond to the ‘moral distress’ of the COVID-19 pandemic<figure><img src="https://images.theconversation.com/files/402376/original/file-20210524-19-1n8ct29.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5532%2C3730&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health-care professions like nursing are at risk of experiencing a post-pandemic exodus of workers due to burnout and moral distress.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The stories we hear and tell help us make meaning of our lives in the world. We communicate our thoughts and feelings, share knowledge and begin dialogue about things that matter. </p>
<p><a href="https://www.cpha.ca/moral-distress-healthcare-public-health-issue">Moral distress</a> occurs when our core values are threatened or compromised, when we know what ethical action is called for and feel powerless to take it. As a nurse and an ethicist and spiritual care provider, we have witnessed the symptoms of moral distress in our clinical, administrative and academic work. </p>
<p>In health care, moral distress can be caused by external pressures such as policy guidelines or limited resources or internal factors such as self-doubt or fear of conflict. When we compromise our core values, we may feel shame, guilt or isolation. And when moral distress is unresolved, <a href="https://www.cma.ca/sites/default/files/pdf/Moral-Distress-E.pdf">health-care workers can experience depression and other mental and spiritual health struggles</a>.</p>
<p>The experience of moral distress among health-care providers <a href="https://dx.doi.org/10.1002/hast.1110">has received much attention during the pandemic</a>. In particular, the nursing profession <a href="https://www.icn.ch/news/covid-19-effect-worlds-nurses-facing-mass-trauma-immediate-danger-profession-and-future-our">anticipates high rates of post-pandemic exodus</a>, almost certainly driven to a substantial degree by accumulated and unresolved moral distress.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Eikx4Eg5-wY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Experts from Johns Hopkins University discuss moral and ethical distress arising during the COVID-19 pandemic.</span></figcaption>
</figure>
<p>Our work examines stories that look at what it means to live well through the COVID-19 pandemic, a grander story that is unprecedented in our lifetimes.</p>
<h2>Moral distress stories</h2>
<p>Early in the pandemic, the promise of returning to normal was tied to the development of a vaccine. At that time, there was little conversation about the challenges of vaccinating enough people to ensure herd immunity. Nor was there conversation about access, equity and staging of vaccination rollout. </p>
<p>Drawing from our own experience and research, we found that questions about the socio-political context of vaccination programs are rampant and complex. The following examples — developed from our experience and research findings — demonstrate how these challenges manifest in daily life.</p>
<p>Lin and her partner received early vaccination due to her partner’s chronic medical condition. As his primary care giver, Lin “jumped the queue” and got an early vaccine. She knows someone with diabetes who has not had their first dose and who lives in the hot spot of Peel Region, just east of Toronto. Was it right that Lin got hers before them?</p>
<p>Lin highly values her family. However, by using her privileged knowledge of the health care system to “jump the vaccine queue,” Lin fears that she compromised her value of caring for all people, especially those who are marginalized. As a result, she feels shame. </p>
<p>Sam followed the directive that the “first vaccine is the best vaccine.” They got the AstraZeneca vaccine. And now, months later, as they watched several provinces withdraw the vaccine for use as a first dose, Sam wonders: “What will happen next? Did I do the right thing or did I not take adequate responsibility for my health? Will my second dose be a different kind of vaccine? What are the risks? And what will happen to all that unused vaccine?”</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/astrazeneca-covid-19-vaccine-faq-why-do-the-age-recommendations-keep-changing-does-it-cause-vipit-blood-clots-is-it-effective-against-variants-158302">AstraZeneca COVID-19 vaccine FAQ: Why do the age recommendations keep changing? Does it cause VIPIT blood clots? Is it effective against variants?</a>
</strong>
</em>
</p>
<hr>
<p>Sam values informed consent and individual responsibility, and has feelings of regret over blindly accepting the first vaccine. Their confidence in science is dwindling. Sam feels powerlessness. </p>
<p>Both Sam and Lin question their core value of global social justice as they watch <a href="https://www.ctvnews.ca/health/coronavirus/more-provinces-are-limiting-the-use-of-the-astrazeneca-vaccine-1.5424950">Canada backing away from the AstraZeneca vaccine in favour of other options</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/402377/original/file-20210524-19-1648ngm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="an illustration of a standing man with a wiry shadow attached to him" src="https://images.theconversation.com/files/402377/original/file-20210524-19-1648ngm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/402377/original/file-20210524-19-1648ngm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/402377/original/file-20210524-19-1648ngm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/402377/original/file-20210524-19-1648ngm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/402377/original/file-20210524-19-1648ngm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/402377/original/file-20210524-19-1648ngm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/402377/original/file-20210524-19-1648ngm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Feelings of being overwhelmed and experiencing frustration and helplessness can cause moral distress in health-care workers and others.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>To live well through this pandemic, we need to understand three things about experiences of moral distress:</p>
<p><strong>1. Moral distress can affect everyone</strong></p>
<p>Events and circumstances during this pandemic have routinely stretched and challenged core values. Not only are people experiencing the mental distress of living in a pandemic, but these feelings are often being compounded by the violation of people’s core values. </p>
<p>When people feel shame, they feel too embarrassed to tell anyone what they fear they have done. So they become increasingly isolated — on top of pandemic isolation. They feel they have damaged the core of their being. </p>
<p>To live well through this pandemic, we need to recognize that feelings of moral uncertainty and distress are normal and real.</p>
<p><strong>2. Moral distress can produce both negative and positive outcomes</strong></p>
<p>Unresolved moral distress can be debilitating. Paradoxically, it can help us to develop moral resiliency — the ability to maintain one’s moral integrity in trying situations, which requires <a href="https://doi.org/10.1111/jocn.13989">experiences of moral adversity</a>. When we practise standing up for what we believe, we can become better able to stand strong in the future. We can also become clearer about what our core values are such as family, caring, social justice, health or relationships. </p>
<p>The relationships that we find in community can help us to explore how to <a href="https://moraldistressproject.med.uky.edu/moral-distress-home">process moral uncertainty</a>.</p>
<p>To live well through this pandemic we need to have our moral stories witnessed and normalized. </p>
<p><strong>3. Moral distress can prompt self-reflection</strong></p>
<p>Good things can come from moral adversity. Education about ethics is crucial including learning about core values and finding words to express core values. Studies show that understanding the language around ethics <a href="https://doi.org/10.1016/j.outlook.2017.03.009">may be a significant factor in helping people resolve moral distress</a>.</p>
<p>Take time to explore your core values. To live well through the pandemic is to know that our choices aren’t ideal and our knowledge is not complete. </p>
<p>We must look beyond ourselves to understand the values of others and the reality we face together.</p><img src="https://counter.theconversation.com/content/160850/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>To live well through and beyond the pandemic, we need to recognize the moral distress experienced by people, and especially health-care workers.Deborah Tregunno, Associate Professor, School of Nursing, Queen's University, OntarioTracy J. Trothen, Professor of Ethics, School of Religion and School of Rehabilitation Therapy, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1597542021-05-06T09:24:02Z2021-05-06T09:24:02ZIt’s possible to build stronger systems to deliver oxygen: here’s what it takes<figure><img src="https://images.theconversation.com/files/397120/original/file-20210426-17-1vlz71d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Family members of COVID-19 infected patients stand in a queue with empty oxygen cylinders outside the oxygen filling centre in New Delhi, India</span> <span class="attribution"><span class="source">Photo by Naveen Sharma/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>COVID-19 is overwhelming hospital oxygen systems. COVID-19 pneumonia creates breathing difficulties leading to low blood oxygen levels (hypoxaemia). Unable to get enough oxygen to supply vital organs, patients with hypoxaemia are at very high risk of death. Supplemental oxygen is the only treatment. </p>
<p>About <a href="https://doi.org/10.1001/jama.2020.2648">20% of COVID-19 patients</a> globally have required hospital admission for oxygen therapy. But <a href="https://dx.doi.org/10.2471/BLT.16.186676">oxygen access was already a challenge</a> for hospitals in low- and middle-income countries, particularly smaller facilities in more remote geographies. This is due to <a href="https://doi.org/10.1002/ppul.24656">three major challenges</a>:</p>
<ul>
<li><p>low-quality, poorly functioning equipment, with inadequate access to maintenance and repair support;</p></li>
<li><p>lack of clinical and technical education and protocols;</p></li>
<li><p>deficiencies in local infrastructure – such as unreliable power supply – and management systems.</p></li>
</ul>
<p>The COVID-19 pandemic has exposed these challenges, leading to horrifying situations, such as the one <a href="https://www.aljazeera.com/news/2021/5/3/india-covid-crisis-lack-of-oxygen-killed-him-not-the-virus">in India</a>. </p>
<p>While the magnitude of this oxygen crisis is unprecedented, the reality of caring for patients without adequate oxygen systems is not new. Every year, <a href="https://doi.org/10.1016/S0140-6736(21)00561-4">around 15 million children</a> are admitted to hospital with life-threatening low blood oxygen levels, due to pneumonia and other conditions like malaria, sepsis and premature birth. </p>
<p>We are part of a <a href="https://www.mcri.edu.au/Oxygen-access">team</a> of health workers, engineers and researchers who support hospitals and governments to build stronger oxygen systems. We’ve been doing this for more than two decades in Africa and Asia-Pacific regions. </p>
<p>Our <a href="https://doi.org/10.9745/GHSP-D-20-00224">new paper</a> outlines the practical ways hospitals can immediately strengthen their oxygen systems. They can improve testing for oxygen levels (pulse oximetry) and oxygen use, support biomedical engineers, and expand on existing oxygen systems with robust equipment and smart design. </p>
<p>Policy makers and programme managers can use our recommendations to ensure investments in oxygen systems are more effective and efficient.</p>
<h2>Poorly functioning systems</h2>
<p>An effective oxygen system requires prompt recognition of those who need oxygen. It then needs a reliable supply and safe delivery to get it to them. Prior to COVID-19, there were gross deficiencies in many countries, illustrated by our detailed <a href="https://doi.org/10.1093/inthealth/ihz009">analysis</a> in Nigeria.</p>
<ul>
<li><p>Less than one in 20 patients had their blood oxygen levels measured. Without access to, and routine use of, pulse oximeters (which measure the level of oxygen in the blood), healthcare workers had no reliable way of determining who to prioritise.</p></li>
<li><p>While more than 80% of hospitals had some oxygen supplies, only 5% of oxygen concentrators worked properly. These machines concentrate oxygen from ambient air. Without access to spare parts or basic maintenance tools, biomedical engineers and technicians faced an impossible task.</p></li>
<li><p>Oxygen costs were high for patients and families. It cost them more than all other admission and treatment costs combined.</p></li>
</ul>
<p>But it doesn’t have to be this way. Our work with hospitals in <a href="https://doi.org/10.1371/journal.pmed.1002951">Nigeria</a>, <a href="https://www.hewatele.org/">Kenya</a>, <a href="https://doi.org/10.1136/archdischild-2020-320107">Papua New Guinea</a> and elsewhere has shown that hospital oxygen systems can be improved and save lives.</p>
<h2>Improving systems</h2>
<p>To make oxygen delivery more effective and efficient, we offer these suggestions:</p>
<p><strong>Pulse oximetry and oxygen use training:</strong> Healthcare workers must be trained in the use of pulse oximetry and oxygen provision. Taking someone’s oxygen saturation level should be a standard procedure for all acutely unwell patients. It allows healthcare workers to target oxygen towards those who need it most and adjust the dose needed. </p>
<p>In many low- and middle-income countries, pulse oximetry and oxygen therapy are <a href="https://academic.oup.com/tropej/article/58/5/389/1656199">largely absent</a> from medical and nursing curricula and clinical guidelines. </p>
<p>Education and support for healthcare workers should also cover basic checks and maintenance of vital equipment. </p>
<p><strong>Assistance for biomedical engineers:</strong> Oxygen is a medicine that depends on technology. It requires effective teamwork between healthcare workers, technicians and managers. However, biomedical engineers and hospital technicians are frequently left out of decision-making processes. This means they often lack maintenance budgets or system support. </p>
<p>Engineers and technicians are already coming up with <a href="https://www.openo2.org/home">innovative solutions</a> to make oxygen delivery more reliable and efficient. With training, tools, spare parts and access to stronger maintenance and transport systems, engineers and technicians can do much to optimise existing oxygen equipment and supply chains. </p>
<p><strong>Expansion of existing oxygen systems:</strong> There are several oxygen source systems. These include: small oxygen bedside concentrators which concentrate oxygen from the air; oxygen plants used to fill oxygen cylinders for distribution; and bulk liquid oxygen which is produced by gas plants and delivered via tanker trucks to fill liquid oxygen tanks at major hospitals.</p>
<p>Robust equipment and smart design should be used to build on what exists. For instance, countries with extractive industries – such as mining – typically have better access to liquid oxygen. Recent experience in India shows that it is possible to <a href="https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/while-industrial-oxygen-has-been-diverted-for-medical-use-problems-in-transportation-and-delivery-remain/articleshow/82234135.cms?from=mdr">divert</a> industrial oxygen supplies for medical use. However, this is only useful if hospitals have the infrastructure and ability to safely store and use liquid oxygen. </p>
<p>The World Health Organisation (WHO) and UNICEF have also released <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance">guidance</a> on oxygen-related equipment and specific guidance for COVID-19. This will help health providers to make better use of what they have. For instance, it includes recommendations on the use of low-cost oxygen bedside concentrators distributing oxygen to patients using simple plastic tubing. </p>
<h2>Benefits for the future</h2>
<p>Over the past year, donors have sought to support low- and middle-income countries to boost their oxygen supply systems. For instance, UNICEF <a href="https://www.unicef.org/supply/coronavirus-disease-covid-19">delivered</a> over 20,000 oxygen concentrators and about 15,000 pulse oximeters to 94 countries. </p>
<p>Hospitals can use our practical <a href="https://www.ghspjournal.org/content/suppl/2020/09/29/GHSP-D-20-00224.DCSupplemental">installation guidance</a> to put this equipment to use rapidly and effectively. Otherwise – without enough understanding on how to integrate them – there’s the risk that they end up in equipment graveyards.</p>
<p>Improving patient outcomes always hinges on doing the basics well. The COVID-19 pandemic offers the opportunity to refocus efforts on the basics of acute care, knowing that improvements in oxygen will benefit patients both now and in the future.</p>
<p><em>Dr Bernard Olayo – founder and chairman of the <a href="https://www.cphdev.org/">Center for Public Health and Development</a> – and Sheillah Bagayana – a Ugandan biomedical engineer – contributed to the research behind, and the writing of, this article</em></p><img src="https://counter.theconversation.com/content/159754/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hamish Graham has received research funding from the Bill and Melinda Gates Foundation, WHO, USAID, UK FCDO, and Netherlands MFA. He is an advisor to WHO, UNICEF, Lifebox Foundation, and member of the Oxygen for Life Initiative, Every Breaths Counts, and United for Oxygen coalitions. </span></em></p><p class="fine-print"><em><span>Adegoke Falade has received research funding from the Bill and Melinda Gates Foundation. He is member of the Oxygen for Life Initiative, Every Breaths Counts, and United for Oxygen coalitions.</span></em></p>An effective oxygen system requires prompt recognition of who needs oxygen, a reliable oxygen supply and safe delivery to those who need it.Hamish Graham, Paediatrician, Royal Children's Hospital; Research Fellow, Centre for International Child Health, Royal Children's HospitalAdegoke Falade, Professor of Paediatrics, Department of Paediatrics, University of IbadanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1570542021-04-28T20:08:28Z2021-04-28T20:08:28ZMy partner or my degree: a choice that exposes how students battle gender inequity<figure><img src="https://images.theconversation.com/files/396953/original/file-20210426-13-1an4puy.jpg?ixlib=rb-1.1.0&rect=0%2C20%2C6720%2C4446&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/lazy-husband-sitting-couch-using-phone-1779932177">Shutterstock</a></span></figcaption></figure><p>The current focus on gender equity has meant universities are promoting and investing in strategies to overcome gender-related factors known to hinder women academics’ success. While these are positive steps, female university students burdened by gender inequities have been largely overlooked. <a href="https://doi.org/10.1080/03075079.2020.1861597">Our research</a> explored the impacts of traditional societal expectations of women’s domestic roles on mature-age nursing students. More than one in four separated from their partners, with most indicating they did this so they could complete their studies. </p>
<p>All our research participants were living with a male partner. In these relationships, traditional gender responsibilities associated with “being female” can threaten their ability to engage and achieve at university. At the same time, the stability of their family unit is undermined. </p>
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Read more:
<a href="https://theconversation.com/how-covid-is-widening-the-academic-gender-divide-146007">How COVID is widening the academic gender divide</a>
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<p>Women students are <a href="https://theconversation.com/yes-women-outnumber-men-at-university-but-they-still-earn-less-after-they-leave-142714">in the majority</a> in Australian higher education. In undergraduate nursing they account for <a href="https://www.voced.edu.au/content/ngv%3A57229">90% of enrolments</a>.</p>
<p>Nursing degrees are steadily losing favour with school leavers but are <a href="http://dx.doi.org/10.1515/1548-923X.2334">increasingly attractive to older women</a>. Many of them are considering a career for the first time after having children. The <a href="http://hdl.voced.edu.au/10707/384852">rise in the average age</a> of nursing students means more are living with a partner than ever before. </p>
<h2>‘Women’s work’ hinders study</h2>
<p>For <a href="https://doi.org/10.1080/03075079.2020.1861597">our research</a>, we conducted 52 in-depth interviews with 29 participants across the degree journey at an Australian university nursing school. Analysis of their responses identified the influences on their studies off traditional societal expectations of women’s roles and responsibilities. </p>
<p>Every participant took main or sole responsibility for childcare and housework before they began their degree. This reflects commonly reported <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0%7E2016%7EMain%20Features%7EEmployment%20Data%20Summary%7E67">divisions of domestic work</a> in Australian households.</p>
<p>The unequal division of duties continued during their time at university – the woman’s study commitment or the time each partner spent in paid work made no difference. Partners remained unwilling to share the domestic load. </p>
<blockquote>
<p>“No he never compromised. To him all he really had as a responsibility was his work.” (Lauren*, 32).</p>
</blockquote>
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<p>
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<strong>
Read more:
<a href="https://theconversation.com/covid-forced-australian-fathers-to-do-more-at-home-but-at-the-same-cost-mothers-have-long-endured-154834">COVID forced Australian fathers to do more at home, but at the same cost mothers have long endured</a>
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<h2>University practices add to the problem</h2>
<p>Aspects of the degree curriculum and its delivery made the women’s situation worse. Most notable was the university’s practice of allocating clinical placements without consulting students. Some placements were far from home. </p>
<p>In addition, hospital placement providers often gave students minimal notice of shift patterns. They were left to struggle to reorganise paid work arrangements and secure childcare. </p>
<blockquote>
<p>“Practical placements are horrendous when you’ve got a young family and you don’t get your shift roster until a week and a half before you go. I mean some hospitals, you get it on the day you turn up there.” (Candice*, 40).</p>
</blockquote>
<figure class="align-center ">
<img alt="Tired nurse completes notes in ward" src="https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396956/original/file-20210426-23-1e31sjk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Work placements far from home, often made with little notice or consultation, add to nursing students’ difficulties.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/overworked-nurse-wrinting-on-clipboard-working-1931087729">Shutterstock</a></span>
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<p>Much-needed student academic and digital support workshops tended to be planned outside the curriculum. This made sessions, especially those held in the early evening, less accessible to these time-poor students. The almost ubiquitous initial lack of digital literacy among the women in this study meant online workshops were similarly inaccessible.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-not-about-you-how-to-be-a-male-ally-158134">'It's not about you': how to be a male ally</a>
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<h2>Compromise and sacrifice</h2>
<p>The stress of the competing demands of the women’s studies and their private lives coupled with the lack of domestic support from partners created tension in their relationships. </p>
<p>Partners resented the time the women took away from the family to study. They often withdrew emotional support over time. Some women described partners as “obstructive” to their academic progress. Most described periods of relationship conflict. </p>
<blockquote>
<p>“It was anger and verbal abuse … He would just put me down as far as my study goes … in a way of demeaning the study, like it doesn’t really matter about my nursing degree at the end of the day.” (Jennifer*, 46). </p>
</blockquote>
<p>The women described how they made compromises to remain at university and appease their partners. Some sacrificed sleep and socialising with friends and family. Most consciously lowered their personal achievement expectations. </p>
<blockquote>
<p>“I had to base my course around my family. I think if I did have more time, more freedom to choose […] [it] would definitely have increased my grades.” (Georgia*, 23).</p>
</blockquote>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-arent-better-multitaskers-than-men-theyre-just-doing-more-work-121620">Women aren't better multitaskers than men – they're just doing more work</a>
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<p>More than a quarter of the women separated from their partners later in their studies. Most of them indicated this had been a conscious decision to enable them to complete their degree. </p>
<blockquote>
<p>“I realised something needs to give and it’s not going to be my degree. It just wasn’t going to work so I gave him the flick.” (Charlotte*, 30).</p>
</blockquote>
<h2>Implications for nursing and an ageing society</h2>
<p>The heterosexual intimate relationship can act as a direct challenge to women nurse students’ progression and achievement. With women studying nursing later in life, this has serious implications for nurse education and the supply of fully prepared graduates to the workforce. </p>
<p>The <a href="https://www.aihw.gov.au/getmedia/19dbc591-b1ef-4485-80ce-029ff66d6930/6_9-health-ageing.pdf.aspx">rise in the nursing needs</a> of Australia’s ageing population compounds the problem of a <a href="https://www.voced.edu.au/content/ngv%3A57229">projected shortage of nurses</a>. These trends heighten the significance of nursing students’ situation. </p>
<p>More widely, the implications of relationship breakdowns on the mental and financial health of those affected should not be forgotten. </p>
<h2>What can universities do?</h2>
<p>The idea of the nurse student as a single autonomous agent who can prioritise the university over “traditionally female” domestic roles at home is at odds with reality. Universities need to acknowledge the substantial impacts of gendered expectations and responsibilities on women students. </p>
<p>Universities are notoriously reluctant to pry into students’ private lives. They see this as outside their remit. In reality, universities can improve engagement opportunities for their women nurse students in many ways. </p>
<p>Some universities are beginning to offer workshops that prepare students for the digital requirements of study at the start of the degree. They are also embedding academic literacy support across the curriculum. </p>
<p>There is still more they can do. Simple strategies include involving students in clinical placements to ensure these are accessible, providing placement information in good time, and providing accessible childcare that meets the ad hoc and changing needs of students. Training of university counsellors could also be expanded to support students in relationship crisis.</p>
<p><em>* Pseudonyms have been used to protect study participants’ privacy.</em></p><img src="https://counter.theconversation.com/content/157054/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Andrew does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nursing students are 90% female, often mature-age students who are still expected to carry most of the housework and childcare load while they study. Something has to give.Lesley Andrew, Course Coordinator, Postgraduate Public Health, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1529352021-01-13T13:30:40Z2021-01-13T13:30:40ZNurses report PTSD symptoms due to the pandemic – here’s why<p>Nurses have been putting themselves in harm’s way every day since the pandemic began. But as coronavirus spreads rapidly in the UK, it has become clear that those in intensive care units are now under more pressure than others. </p>
<p>Hospitals are <a href="https://www.theguardian.com/world/2021/jan/08/the-worst-by-a-cataclysmic-margin-the-race-to-save-the-nhs-from-covid">nearing capacity</a> in many parts of the country, and in some regions <a href="https://www.reuters.com/article/health-coronavirus-britain-morgue/temporary-morgues-set-up-as-uk-hospitals-run-out-of-space-idUSL8N2JN33Z">temporary mortuaries</a> have been set up as hospital morgues begin to overflow. </p>
<p>At the end of 2020, <a href="https://inews.co.uk/news/health/coronavirus-latest-major-london-hospital-disaster-medicine-mode-814631">a leaked email</a> revealed that the Royal London Hospital was operating in “disaster-medicine mode” and unable to provide high-standard critical care. Cases have only risen since then. </p>
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<a href="https://images.theconversation.com/files/378320/original/file-20210112-13-1kaxwos.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graph showing sharp rise in daily new confirmed COVID-19 cases in a rolling seven-day average." src="https://images.theconversation.com/files/378320/original/file-20210112-13-1kaxwos.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/378320/original/file-20210112-13-1kaxwos.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/378320/original/file-20210112-13-1kaxwos.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/378320/original/file-20210112-13-1kaxwos.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/378320/original/file-20210112-13-1kaxwos.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/378320/original/file-20210112-13-1kaxwos.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/378320/original/file-20210112-13-1kaxwos.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://ourworldindata.org/coronavirus">OurWorldInData</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>This situation has been brewing for a while. When the pandemic struck the UK, the National Health Service in England was already short of 40,000 nurses due to lacking government investment, inadequate workforce planning and the <a href="https://www.nursingtimes.net/news/workforce/even-more-nurses-considering-quitting-the-profession-survey-reveals-17-07-2020/">ongoing mass exit of nurses from the profession</a>. </p>
<p>Now, on top of these pre-existing workforce issues and <a href="https://www.theguardian.com/world/2021/jan/11/england-warned-prepare-worst-weeks-covid-pandemic-chris-whitty">high rates of infection, hospitalisation and deaths</a>, nurses are also grappling with <a href="https://www.bbc.co.uk/news/uk-england-humber-55579268">widespread staff sickness due to COVID-19</a>. </p>
<h2>Pressure on intensive care</h2>
<p>The recognition of how highly skilled and essential nurses truly are has only now begun to dawn on some people, including healthcare leaders. </p>
<p>Working in an ICU requires a unique skill set, which makes it difficult to fully staff the units when they are so busy. Some non-specialists have been <a href="https://www.rcn.org.uk/get-help/rcn-advice/redeployment-and-covid-19">re-deployed to critical care</a> from other areas, but all these staff need special training and supervision, causing further stress for the already overstretched ICU nurses. </p>
<p>The standard ratio for ICUs is usually one nurse per critically ill patient. But in response to the pandemic, guidelines have changed so that one nurse can be expected to care for up to <a href="https://www.rcn.org.uk/news-and-events/news/uk-nurse-staffing-ratios-in-icu-revised-to-help-manage-second-surge-of-covid-19-131120">four patients</a> depending on the nature of their illness. </p>
<p>This means at any one time, there may not be enough people on hand to safely turn patients in bed, resulting in <a href="https://pubmed.ncbi.nlm.nih.gov/30666686/">joint pain and back injury</a>.</p>
<p>The physical strain of <a href="https://svn.bmj.com/content/5/3/302">wearing PPE for long shifts</a>, which among other things prevents nurses from being able to drink or eat, only adds to the burden for staff.</p>
<h2>Psychological trauma</h2>
<p>Nursing as a profession has developed <a href="https://pubmed.ncbi.nlm.nih.gov/28929939/#:%7E:text=Nursing%20models%20and%20theories%20are,guarantee%20the%20ethical%20professional%20practice.&text=With%20development%20of%20these%20concepts,the%20quality%20of%20nursing%20care">models and theories</a> to underpin care, which help maintain standards and ensure that nurses are able to offer emotional support and comfort to those they care for. </p>
<p>Witnessing people dying without the support of loved ones is particularly emotionally stressful and directly challenges nurse’s professional standards of care. </p>
<hr>
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<strong>
Read more:
<a href="https://theconversation.com/covid-has-exposed-a-long-running-shortage-of-nurses-that-is-putting-nhs-patients-at-risk-150116">COVID has exposed a long-running shortage of nurses that is putting NHS patients at risk</a>
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<p>Being forced to make constant, impossible choices about priorities is heart-breaking for nurses. Many have spoken out about how the high rate of COVID deaths, which sometimes results in multiple patients losing their lives within one shift, is deeply traumatic for staff. Some have described working in an ICU as being like <a href="https://www.bbc.co.uk/news/uk-england-humber-55579268">stepping into a war zone</a>. It’s no surprise, then, that a new study has found that <a href="https://www.theguardian.com/society/2021/jan/13/nhs-icu-staff-ptsd-severe-depression-anxiety">40% of ICU staff in England</a> are suffering from symptoms consistent with PTSD. </p>
<p>Feelings of not being able to control what is happening to them or those they care for can result in toxic workplace stress which has a measurable <a href="https://oem.bmj.com/content/59/1/67">negative impact on health and wellbeing</a>. The mental health of nurses working under this pressure is <a href="https://www.mind.org.uk/workplace/coronavirus-and-work/being-a-nurse-during-coronavirus/">already deteriorating</a> and can result in long-term psychological damage. </p>
<h2>Hard work for little reward</h2>
<p>We should not forget that nursing is not a well-paid job, with many nurses earning <a href="https://www.bbc.com/news/uk-52312038">below the median salary for the UK</a>. </p>
<p>Low pay is the <a href="https://nursingnotes.co.uk/news/workforce/poor-pay-treatment-leads-sharp-rises-nurses-planning-leaving/">most common reason</a> cited by nurses for wanting to leave the profession. There seems little doubt that the combination of the pandemic with stress, declining standards and low pay will lead to <a href="https://rcni.com/nursing-standard/newsroom/news/covid-19-exhausted-nurses-could-leave-profession-icu-matron-warns-170576">further departures</a>. </p>
<p>Speaking out about these challenges is not easy for nurses – the NHS in England is currently under a <a href="https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/11/KW_Level_4-letter_4Nov.pdf">level 4 national incident</a> which means all official communication to the public and the media is supposed to be controlled centrally. This leaves many to suffer in silence. </p>
<p>Throughout the pandemic, nurses and other essential workers have been described as “heroes”. The Clap for Our Carers movement from the UK’s first lockdown, designed to help the public give public thanks to frontline pandemic workers, has been brought back for 2021 under the new title, <a href="https://clapforourcarers.co.uk/">Clap for Heroes</a>.</p>
<p>But nurses are not heroes. They are technically expert professional carers with unique skills. Clapping is a poor substitute for allowing them the freedom to speak up about the concerns they may have about their own health and wellbeing and those they care for.</p><img src="https://counter.theconversation.com/content/152935/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ann Hemingway does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nurses are not heroes – they are technically expert professional carers with unique skills. And they are struggling.Ann Hemingway, Professor of Public Health, Bournemouth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1501162020-12-17T14:26:38Z2020-12-17T14:26:38ZCOVID has exposed a long-running shortage of nurses that is putting NHS patients at risk<p>“Protect the NHS” has been a recurring message that has shaped the UK’s response to COVID-19. The danger that the pandemic could <a href="https://www.bbc.co.uk/news/health-54440392">overwhelm the NHS</a> has never been far out of sight. As we approach the <a href="https://www.gov.uk/guidance/guidance-for-the-christmas-period">five-day relaxation</a> of restrictions for Christmas, the question of whether the NHS will be able to cope is as pertinent now as it was in March. </p>
<p>What has become apparent is that the major limit to treatment capacity is not the number of hospital beds, nor even the number of intensive care beds with ventilators, it is the number of <a href="https://www.nursingtimes.net/news/hospital/not-enough-intensive-care-nurses-for-coronavirus-outbreak-12-03-2020/">appropriately skilled nurses</a> available to provide care. The pandemic has exposed an achilles heel: a deficit in nursing. </p>
<p>This isn’t a new problem. Around 10% of positions for <a href="https://www.rcn.org.uk/professional-development/become-a-nurse#becomeanurse">registered nurses</a> in the NHS were vacant when the pandemic first hit. Analysis from the charity the <a href="https://www.health.org.uk/publications/reports/building-the-nhs-nursing-workforce-in-england">Health Foundation</a> has found that over the last ten years, NHS activity (the number of patients seen and care provided) has risen year on year, but without a corresponding rise in the nursing workforce. </p>
<p>Between 2010 and 2017, the number of nurses in the NHS barely changed. From 2017 to June 2020 there was a <a href="https://www.health.org.uk/publications/reports/building-the-nhs-nursing-workforce-in-england">4.8% rise</a>, but the gap between amount of the work to do and nursing numbers has continued to widen. As the shortage of registered nurses persists, the NHS has employed larger numbers of support staff, such as <a href="https://www.health.org.uk/sites/default/files/upload/publications/2019/S05_Falling%20short_The%20NHS%20workforce%20challenge.pdf#page=20">nursing and healthcare assistants</a>. In the past year, the growth in support staff has been twice that of registered nurses. </p>
<h2>A dangerous situation</h2>
<p>Research points to the risks of not having enough registered nurses on duty. A <a href="https://doi.org/10.1016/S0140-6736(13)62631-8">nine-country study</a> from 2014 found that increasing a nurse’s workload by one patient increased the likelihood of a patient dying by 7%. And in our own research, my colleagues and I found that when staffing levels were lower, nurses in England were more likely to report that <a href="http://dx.doi.org/10.1136/bmjqs-2012-001767">necessary care was left undone</a>. </p>
<p><a href="https://doi.org/10.1016/j.ijnurstu.2017.08.004">Further analysis</a>, led by the University of Southampton, found that the amount of “care left undone” contributes to the risk of unexpected death among hospital patients. Also, hospitals relying on <a href="http://dx.doi.org/10.1136/bmjqs-2016-005567">lower levels of registered nurses</a> and higher levels of lesser-trained support staff have higher mortality rates. </p>
<figure class="align-center ">
<img alt="A nurse operating a ventilator" src="https://images.theconversation.com/files/375438/original/file-20201216-15-15oky4b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/375438/original/file-20201216-15-15oky4b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/375438/original/file-20201216-15-15oky4b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/375438/original/file-20201216-15-15oky4b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/375438/original/file-20201216-15-15oky4b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/375438/original/file-20201216-15-15oky4b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/375438/original/file-20201216-15-15oky4b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nurses are critical for providing care to patients with severe COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/artificial-lung-ventilation-monitor-intensive-care-1686602005">Terelyuk/Shutterstock</a></span>
</figcaption>
</figure>
<p>The risks of low nursing numbers were highlighted by the <a href="https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry">Francis Inquiry</a> in 2013. Reductions in nurse numbers – made in previous years to achieve short-term savings – had not taken into account the risks to patients. The inquiry revealed the lack of policy or standards on nurse staffing levels and recommended that national guidelines be developed, based on research. The National Institute for Health and Care Excellence (Nice) subsequently published <a href="https://www.nice.org.uk/guidance/sg1">guidelines on “safe staffing”</a> in 2014.</p>
<p>The inquiry and the Nice guidelines succeeded in raising awareness of the need to have sufficient registered nurses on duty. When surveyed in 2017, <a href="https://eprints.soton.ac.uk/430184/1/7315_01_Safe_Staffing_Report_v3.pdf">three-quarters of chief nurses</a> said that support from NHS boards for bolstering the nursing workforce had risen since the inquiry. </p>
<p>Still, unsafe staffing levels persisted in many NHS trusts, primarily as they were unable to recruit the registered nurses needed. Policy had succeeded in <a href="https://doi.org/10.1016/j.healthpol.2019.03.011">motivating a desire for safe staffing</a> but had not created the investment in the nursing workforce needed to deliver it. </p>
<h2>Plugging the gap</h2>
<p>In December 2019, the UK government recognised the need to address this long-term nursing shortage. It pledged to increase the number of registered nurses in the NHS by 50,000 by 2024-25. But how feasible is this target? </p>
<p>Interest in nursing has increased; 23% more students have been <a href="https://www.ucas.com/data-and-analysis/undergraduate-statistics-and-reports/statistical-releases-daily-clearing-analysis-2020">accepted onto nursing courses</a> in England in 2020 than in 2019. The number of applicants rose sharply after March 2020 – the profile of nursing having been potentially heightened by COVID-19. </p>
<p>But the UK’s <a href="https://www.health.org.uk/publications/reports/building-the-nhs-nursing-workforce-in-england">domestic supply of nurses</a> per head of population is well below the OECD average and is insufficient to meet demand. So the NHS relies on nurses from abroad to make up the difference. A third of nurses first entering the UK register in 2019-20 trained outside the UK. In total, 15% of the UK’s registered nurses trained elsewhere – more than double the OECD average.</p>
<figure class="align-center ">
<img alt="Students earing masks in a lecture theatre at university" src="https://images.theconversation.com/files/375439/original/file-20201216-15-8no29c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/375439/original/file-20201216-15-8no29c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/375439/original/file-20201216-15-8no29c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/375439/original/file-20201216-15-8no29c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/375439/original/file-20201216-15-8no29c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/375439/original/file-20201216-15-8no29c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/375439/original/file-20201216-15-8no29c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The pandemic appears to have persuaded more school leavers to become nurses, which will help raise domestic supply.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/education-healthcare-pandemic-concept-african-student-1734106484">Syda Productions/Shutterstock</a></span>
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</figure>
<p>To achieve the government’s target, the Health Foundation notes that England will need to be able to recruit an average of <a href="https://www.health.org.uk/publications/reports/building-the-nhs-nursing-workforce-in-england">5,000 nurses a year</a> from outside the UK between now and 2025. With Brexit ending the free movement of labour to and from the EU, and COVID-19 causing travel disruptions for the foreseeable future, this will be challenging. </p>
<p>The <a href="https://www.health.org.uk/publications/reports/building-the-nhs-nursing-workforce-in-england">Health Foundation</a> also notes that increasing domestic supply is a must. To do this, we’ll need to increase university capacity and fix the lack of clinical placements for students, which are typical bottlenecks. The Council of the Deans of Health, which represents UK universities that teach nurses, <a href="https://councilofdeans.org.uk/wp-content/uploads/2020/07/130720-PAC-response-JN-FN.pdf">has proposed</a> offering <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877810/">simulation-based clinical experience</a> – using lifelike virtual environments, mannequins, role-playing and trained actors to replicate treating real patients – as well as <a href="https://www.nursingtimes.net/opinion/expanding-the-nursing-workforce-to-respond-to-covid19-pandemic-safe-and-effective-options-18-03-2020/">reducing the total clinical hours</a> needed to qualify as a registered nurse (the required hours in the EU are double those needed to qualify in the US and Australia). We also need to look at expanding the faster two-year graduate entry programme.</p>
<p>Achieving net growth will also require lowering the number of nurses leaving the profession. Around 33,000 (10%) nurses <a href="https://www.health.org.uk/publications/long-reads/health-and-social-care-workforce">exit the NHS</a> each year, many citing <a href="https://www.nmc.org.uk/globalassets/sitedocuments/nmc-register/march-2020/nmc-register-march-2020.pdf">“too much pressure”</a> as the cause. Arguably a modest <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/ecaf.12218">oversupply of nurses</a> is what we should be aiming for, as this reduces the costs of high turnover and reliance on temporary cover.</p>
<p>Meeting the 50,000 target is a beginning, not an end. Setting a top-down target represents a political attempt to galvanise a system that has been failing for years to train and retain the nurses it needs, relying on one short-term fix after the next. COVID-19 has exposed a national deficit in nursing skills that will require longer-term vision, robust plans based on accurate data, and investment to resolve.</p><img src="https://counter.theconversation.com/content/150116/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Ball (as an employee of the University of Southampton) has received research funding from the Department of Health and Social Care to research safe staffing policy and the National Institute of Health Research to research the effect of staffing on outcomes. As a principal investigator, she currently receives EU Horizon 2020 funding to research the relationship between organisational factors (including staffing) and staff wellbeing. She is a coauthor of the Health Foundation report "Building the NHS Nursing Workforce in England". She is a member of the Royal College of Nursing. </span></em></p>More patients die if there are fewer nurses available – so the UK must resolve its current shortage.Jane Ball, Professor of Nursing Workforce Policy, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1490302020-11-20T13:23:15Z2020-11-20T13:23:15ZAmid a raging pandemic, the US faces a nursing shortage. Can we close the gap?<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/370088/original/file-20201118-23-1djmf86.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/370088/original/file-20201118-23-1djmf86.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/370088/original/file-20201118-23-1djmf86.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=255&fit=crop&dpr=1 600w, https://images.theconversation.com/files/370088/original/file-20201118-23-1djmf86.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=255&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/370088/original/file-20201118-23-1djmf86.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=255&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/370088/original/file-20201118-23-1djmf86.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=321&fit=crop&dpr=1 754w, https://images.theconversation.com/files/370088/original/file-20201118-23-1djmf86.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=321&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/370088/original/file-20201118-23-1djmf86.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=321&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://www.nursingworld.org/practice-policy/workforce/">American Nurses Association</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>With a <a href="https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html">sharp increase in U.S. COVID-19 cases</a> this fall and <a href="https://www.npr.org/sections/coronavirus-live-updates/2020/11/14/934973850/u-s-adds-184-000-coronavirus-cases-in-one-day-with-no-end-in-sight">hospitals nearing capacity</a> in parts of the <a href="https://www.npr.org/sections/health-shots/2020/11/10/933253317/covid-19-hospitalizations-are-surging-where-are-hospitals-reaching-capacity">Midwest and West</a>, health care workers nationwide are scrambling to save lives – at great personal risk. </p>
<p>But the extraordinary number of people flooding U.S. hospitals has shined a spotlight on another crisis: the country’s <a href="https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/NCHWA_HRSA_Nursing_Report.pdf">nursing shortage</a>. “While we have beds, those beds are only as good as the staff that you can place around them,” said Dave Dillon, a spokesman for the Missouri Hospital Association, quoted in the <a href="https://www.washingtonpost.com/climate-environment/2020/11/11/coronavirus-soars-hospitals-hope-avoid-an-agonizing-choice-who-gets-care-who-goes-home/">Washington Post</a>.</p>
<h2>High risk</h2>
<p>The pandemic has created unprecedented challenges for nurses, including <a href="https://www.nbcnews.com/news/us-news/why-some-nurses-have-quit-during-coronavirus-pandemic-n1201796">fear of workplace exposure</a>. Since nurses have the most direct, hands-on patient contact, <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6943e3.htm?s_cid=mm6943e3_w">they face the greatest risk of infection</a> of all health care workers. Many have been <a href="https://www.healthline.com/health-news/what-its-like-to-be-a-nurse-working-on-the-front-line-of-covid-19#The-moving-stories-we-all-need-to-hear">reassigned</a> to the emergency room, “COVID units” or other high-risk departments. </p>
<p>It’s become an extremely dangerous job. More than half of the 20,000 nurses <a href="https://www.nursingworld.org/%7E4a558d/globalassets/covid19/ana-ppe-survey-one-pager---final.pdf">surveyed</a> by the American Nurses Association last summer <a href="https://www.bloomberg.com/news/articles/2020-09-01/nurses-say-they-re-short-on-masks-other-protection-supplies">reported</a> having to reuse single-use masks or <a href="https://www.nursingworld.org/news/news-releases/2020/new-survey-findings-from-21k-us-nurses--ppe-shortages-persist-re-use-practices-on-the-rise-amid-covid-19-pandemic/">treat patients with little or no personal protective equipment</a>. Many are working 12- to 16-hour shifts. Some <a href="https://www.nbcnews.com/news/us-news/north-dakota-lets-healthcare-workers-covid-stay-job-record-surge-n1247487">who have tested positive for the virus</a> have been asked to continue working to care for the glut of patients. They face <a href="https://www.nbcnews.com/health/health-news/public-health-workers-fighting-covid-19-are-threatened-violence-forced-n1230501">threats of physical harm</a> from those who call the virus a hoax. </p>
<p>Some 36% of health care workers <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6943e3.htm?s_cid=mm6943e3_w">hospitalized</a> with COVID-19 were nurses or nursing assistants, according to U.S. Centers for Disease Control and Prevention data. As of September, <a href="https://www.nationalnursesunited.org/press/new-report-reveals-widespread-government-failure-track-and-report-data-covid-19-deaths">213 registered nurses</a> had succumbed to the virus. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/369703/original/file-20201117-13-1x7oe8n.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/369703/original/file-20201117-13-1x7oe8n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369703/original/file-20201117-13-1x7oe8n.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=468&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369703/original/file-20201117-13-1x7oe8n.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=468&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369703/original/file-20201117-13-1x7oe8n.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=468&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369703/original/file-20201117-13-1x7oe8n.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=588&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369703/original/file-20201117-13-1x7oe8n.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=588&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369703/original/file-20201117-13-1x7oe8n.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=588&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nurses have protested in front of the White House and across the country to highlight inadequate staffing and scarce personal protective equipment amidst the COVID-19 pandemic.</span>
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<p>Working conditions have sparked protests in front of the White House and across the country. In May, the New York State Nurses Association filed <a href="https://www.nysna.org/press/2020/nys-nurses-association-files-three-lawsuits-protect-nurses-health-and-safety#.X7LCbC2ZN27">three lawsuits</a> against the New York State Health Department and two hospitals over safety.</p>
<h2>The nursing crisis</h2>
<p>Some <a href="https://www.nursingworld.org/ana/about-ana/">4 million registered nurses</a> make up the U.S. workforce; about 60% <a href="https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/nssrn-summary-report.pdf">work in hospitals</a>. By 2022, the nation <a href="https://www.nursingworld.org/practice-policy/workforce/">needs 1.1 million new RNs</a> to avoid a nursing shortage, according to the U.S. Bureau of Labor Statistics. </p>
<p>Hospitals can’t function without enough nurses, who spend more time caring for patients than any other health care professional. To keep hospitals staffed amid current <a href="https://nightingale.edu/blog/nursing-shortage-by-state/">shortages</a>, some administrators are <a href="https://www.washingtonpost.com/climate-environment/2020/11/11/coronavirus-soars-hospitals-hope-avoid-an-agonizing-choice-who-gets-care-who-goes-home/">replacing nurses with technicians</a> or asking <a href="https://www.washingtonpost.com/climate-environment/2020/11/11/coronavirus-soars-hospitals-hope-avoid-an-agonizing-choice-who-gets-care-who-goes-home/">nonhospital nurses to work in hospitals</a>. These are life-and-death decisions: choosing either to treat patients under circumstances <a href="https://www.ncbi.nlm.nih.gov/books/NBK2657/">that could risk medical errors</a> – or turn them away. </p>
<h2>What caused this crisis?</h2>
<p>My work as a nurse researcher and professor is to create a highly educated, competent nursing workforce and advance the impact of nursing on the health and wellness of our nation. I’ve found that <a href="http://healthworkforcestudies.com/news/state_of_the_nursing_workforce_paper.pdf">current and projected shortages</a> have many causes and vary widely, with the <a href="https://nightingale.edu/blog/nursing-shortage-by-state/">largest shortfalls in southern and western states</a>. </p>
<p>Some of the looming problem is demographic. The <a href="https://www.ncsbn.org/workforce.htm">average age of a U.S. nurse</a> is 51, and <a href="https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/NCHWA_HRSA_Nursing_Report.pdf">1 million nurses will be eligible for retirement in 10 to 15 years</a>. Nursing schools are expanding, but <a href="https://www.sumnercollege.edu/blog/nursing-shortage-2/">it’s not enough to fill the void</a>. </p>
<p>As the nursing workforce shrinks, the stress on the health care system is rising. The nation’s 73 million baby boomers are aging, with many <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464018/">suffering from chronic illnesses</a> – such as <a href="https://www.cdc.gov/chronicdisease/index.htm">heart disease, cancer and diabetes</a> – that require intensive levels of care.</p>
<h2>A dangerous, stressful career</h2>
<p>Under normal circumstances, nursing is considered <a href="https://work.chron.com/nursing-stressful-career-8152.html">one of the most stressful careers</a>. Demands of the job tend to take precedent over self-care; one <a href="https://doi.org/10.1097/JOM.0000000000001198">study</a> found that 68% of nurses put their patients’ health and safety before their own. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/369721/original/file-20201117-15-t2m7at.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/369721/original/file-20201117-15-t2m7at.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369721/original/file-20201117-15-t2m7at.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=706&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369721/original/file-20201117-15-t2m7at.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=706&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369721/original/file-20201117-15-t2m7at.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=706&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369721/original/file-20201117-15-t2m7at.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=887&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369721/original/file-20201117-15-t2m7at.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=887&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369721/original/file-20201117-15-t2m7at.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=887&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A nurse shows signs of fatigue from working long hours: Lines from her mask are etched into her face.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/fatigued-healthcare-worker-royalty-free-image/1220020355?adppopup=true">RichLegg/Getty Images</a></span>
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<p>An American Nurses Association <a href="https://www.nursingworld.org/%7E4aeeeb/globalassets/practiceandpolicy/work-environment/health--safety/ana-healthriskappraisalsummary_2013-2016.pdf">report</a> revealed that the nursing workforce suffers from widespread health and wellness problems. <a href="https://www.healthynursehealthynation.org">Many nurses</a> are overweight and don’t get adequate sleep; three-fifths work 10 or more hours a day. </p>
<p>The job places nurses at <a href="https://www.bls.gov/opub/mlr/2018/article/occupational-injuries-and-illnesses-among-registered-nurses.htm">high risk of injury and illness</a>. The dangers include moving and lifting heavy patients and equipment as well as <a href="https://www.americansentinel.edu/blog/2017/09/26/nurses-face-workplace-hazards/">exposure</a> to infectious diseases, chemicals and radioactive materials. </p>
<p>Working under intense stress causes burnout in about half of all nurses. It may spark physical or emotional ailments, drug or alcohol misuse or depression. Nurses have a <a href="https://nam.edu/nurse-suicide-breaking-the-silence/">substantially higher risk of suicide</a> <a href="https://www.medpagetoday.com/nursing/nursing/81003">than the general population</a>.</p>
<h2>Pandemic nursing</h2>
<p>The health of the nation’s nurses needs immediate attention. Tired, sick burned-out nurses can’t provide the best care and are <a href="https://journals.lww.com/joem/Abstract/2018/02000/A_National_Study_Links_Nurses__Physical_and_Mental.3.aspx">more likely to quit their jobs</a> than those with better working conditions. </p>
<p>But now, the pandemic has made a tough job exponentially harder. It’s placed health care workers in war zone-like circumstances that they never trained for – or wanted. Picture the shock, for example, of a pediatric nurse relocated from the newborn nursery to a COVID-19 ward.</p>
<p>In a nationwide <a href="https://www.feedtrail.com/newly-released-holliblu-and-feedtrail-covid-19-nurse-survey-has-finger-on-the-pulse-of-nursing-professionals-nationwide-as-featured-in-nbc-nightly-news-with-stephanie-gosk/">survey</a> last spring, more than 60% of the 1,200 nurses interviewed said they were considering quitting their jobs – or leaving the profession altogether. </p>
<h2>Rebuilding a strong nursing force</h2>
<p>Without serious efforts to recruit more nurses and improve working conditions, <a href="https://www.aacnnursing.org/News-Information/Position-Statements-White-Papers/Reverse-Shortage">the U.S. is in danger</a> of serious breakdowns in the health care system. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>There are many ways to <a href="https://www.aacnnursing.org/News-Information/Position-Statements-White-Papers/Reverse-Shortage">address the nursing shortage</a>. Solutions include offering better salary and benefits, saner work hours and less physically demanding roles for older, experienced nurses to keep them working longer. Nonprofit initiatives like the “<a href="https://www.healthynursehealthynation.org">Healthy Nurse Healthy Nation</a>” program can help improve health and wellness. Reaching out to youth and continued funding for nursing education under the <a href="http://nann.org/uploads/Advocacy_Fact_Sheets/2016_Title_VIII.pdf">Public Health Service Act</a> will help spark interest in the profession and build a more diverse workforce.</p>
<p><a href="https://campaignforaction.org/nurses-key-meeting-americas-health-care-needs/">A strong nursing workforce</a> is essential to the health and wellness of the nation. Our health care system and our lives may depend on it.</p><img src="https://counter.theconversation.com/content/149030/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rayna M. Letourneau does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The COVID-19 pandemic has shined a spotlight on another US medical emergency: a serious shortage of nurses.Rayna M. Letourneau, Assistant Professor of Nursing, University of South FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1469812020-10-19T12:22:49Z2020-10-19T12:22:49Z7 tips for staying safe as COVID-19 cases rise and colder weather heightens the risk<figure><img src="https://images.theconversation.com/files/364029/original/file-20201016-17-1qm2rr1.jpg?ixlib=rb-1.1.0&rect=11%2C5%2C3952%2C2574&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Simple steps like wearing a face mask can lower the risk of getting COVID-19 for the wearers and those around them.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-wearing-a-protective-mask-is-seen-in-union-square-on-news-photo/1206290366">Jennah Moon/Getty Images</a></span></figcaption></figure><p>As temperatures fall, people are spending more time indoors. That heightens the risk of the coronavirus spreading, but there are some simple steps you can take to help protect yourself and everyone around you.</p>
<p>It’s easy to get tired of wearing masks and practicing social distancing. There has even been some <a href="https://www.washingtonpost.com/nation/2020/10/14/coronavirus-covid-live-updates-us/">talk from the White House</a> about <a href="https://www.politico.com/news/2020/10/06/trump-herd-immunity-scientists-426911">herd immunity</a> – the idea that if enough people get infected, the virus won’t be able to spread.</p>
<p>But the U.S. <a href="https://coronavirus.jhu.edu/map.html">isn’t anywhere close</a> to herd immunity for SARS-CoV-2, estimated to be reached when <a href="https://www.washingtonpost.com/opinions/tom-frieden-herd-immunity-wrong-solution-coronavirus/2020/10/16/acb4ae8a-0fe6-11eb-8074-0e943a91bf08_story.html">about 60%</a> <a href="https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808">to 70% of the population</a> has been infected – likely more than 200 million people. Without a vaccine, hospitals would be overwhelmed by the illnesses and <a href="https://www.nytimes.com/2020/05/01/opinion/sunday/coronavirus-herd-immunity.html">hundreds of thousands</a> <a href="https://coronavirus.jhu.edu/map.html">more people</a> <a href="https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---12-october-2020">would die</a>. We also don’t know <a href="https://science.sciencemag.org/content/early/2020/10/13/science.abe5960">how long immunity lasts</a>.</p>
<p>Since we don’t have an approved vaccine in widespread use yet, protective measures are still essential. As a nursing school dean, I recommend taking these seven simple steps to protect yourself and your loved ones and reduce the spread of COVID-19.</p>
<p><iframe id="q6J6O" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/q6J6O/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Avoid crowds and keep some distance</h2>
<p>Avoid the <a href="https://www.who.int/images/default-source/wpro/countries/malaysia/infographics/three-3cs/final-avoid-the-3-cs-poster.jpg?sfvrsn=638335c1_2">3 C’s</a> – closed, crowded and close contact. This gets harder as the seasons change and more activities move indoors.</p>
<p>When people <a href="https://www.youtube.com/watch?v=GSPv04IJvpI&feature=emb_logo">sing</a>, shout or even just talk, they send tiny respiratory droplets into the air. If infected droplets get into your eyes, nose or mouth, you can get infected. Staying 6 feet away is a good rule of thumb, but it doesn’t protect you from everything. The tiniest of these droplets, <a href="https://theconversation.com/when-covid-19-superspreaders-are-talking-where-you-sit-in-the-room-matters-145966">known as aerosols</a>, can linger in the air for hours.</p>
<p>The risks of contracting COVID-19 increase in inadequately ventilated spaces where people spend long periods together in close proximity. Outbreaks have been linked to restaurants, <a href="https://doi.org/10.1111/ina.12751">choir practices</a>, fitness classes, nightclubs and other spots where people congregate. You can still find ways to exercise outside, though. Try going for a walk with a friend. Virtual events can also bring people together safely.</p>
<h2>Wear a face mask</h2>
<p>Face masks can <a href="https://theconversation.com/covid-19-masks-faqs-how-can-cloth-stop-a-tiny-virus-whats-the-best-fabric-do-they-protect-the-wearer-146822">reduce the virus’s spread</a> by stopping droplets people breathe out and filtering some of what they breathe in. They are especially important in crowded and poorly ventilated areas.</p>
<p>To wear the mask correctly, start by cleaning your hands before you put it on, and make sure the mask fits securely over your nose, mouth and chin. When the mask doesn’t cover your nose, you’re giving the virus an easy route for infection.</p>
<p>If you wear a fabric mask, make sure it has two or more layers. </p>
<h2>Avoid touching your eyes, nose and mouth</h2>
<p>Your hands touch many surfaces and can pick up viruses. Once contaminated, hands can then transfer the virus to your eyes, nose or mouth. From there, the virus can infect you. </p>
<figure class="align-center ">
<img alt="A woman in face mask and jacket sits outside a bakery." src="https://images.theconversation.com/files/364030/original/file-20201016-15-i36z4x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/364030/original/file-20201016-15-i36z4x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/364030/original/file-20201016-15-i36z4x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/364030/original/file-20201016-15-i36z4x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/364030/original/file-20201016-15-i36z4x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/364030/original/file-20201016-15-i36z4x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/364030/original/file-20201016-15-i36z4x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Outdoor activities that made socializing safely easier in summer get tougher as temperatures drop.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/person-dines-outside-breads-bakery-on-the-upper-west-side-news-photo/1280061662">Noam Galai/Getty Images</a></span>
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<h2>Wash your hands</h2>
<p>Simply <a href="https://www.cdc.gov/handwashing/when-how-handwashing.html">washing your hands</a> can reduce the spread of viruses. Regularly and thoroughly clean your hands for at least 20 seconds with an alcohol-based hand rub or wash them with soap and water. This eliminates germs, including viruses.</p>
<p>Fall and winter also bring more colds. When you feel the need to cough or sneeze, cover your mouth and nose with your bent elbow or tissue. Then dispose of the used tissue immediately into a closed bin and wash your hands. By following good “respiratory hygiene,” you protect the people around you from viruses, including those that cause the common cold, flu and COVID-19.</p>
<h2>Keep surfaces clean</h2>
<p>Clean and disinfect surfaces in your home frequently, especially those people touch regularly, such as door handles, faucets and phone screens.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1315593013184221184"}"></div></p>
<h2>Recognize the symptoms</h2>
<p>Until the U.S. has an approved vaccine with reliable immunity and it’s being used, this pandemic remains a serious health threat. Being able to recognize the <a href="https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html">symptoms of COVID-19</a> is important. </p>
<p>Common symptoms of COVID-19 include, fever, dry cough and fatigue. Other symptoms that may affect some patients include loss of taste or smell, aches and pains, headache, sore throat, nasal congestion, red eyes, diarrhea or skin rash. </p>
<p>Some of these symptoms overlap with the common cold, but it’s best to err on the side of safety. <a href="https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html">If you feel sick or have a fever and difficulty breathing</a>, call your doctor or hospital and seek help. If you experience less severe symptoms, self-isolate until you recover, even if the symptoms seem mild. Call your health care provider or see the Centers for Disease Control and Prevention <a href="https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/coronavirus-self-checker.html">Coronavirus Self-Checker</a> for additional support. If you need to leave your house, wear a face mask to avoid infecting others.</p>
<p>Keep up to date on COVID-19 information and risks from local and <a href="https://www.cdc.gov/coronavirus/2019-ncov/your-health/index.html">national health authorities</a>.</p>
<h2>Take care of your mental health</h2>
<p>During the stress and upheaval of the pandemic, don’t forget to take care of your mental health and well-being. </p>
<p>Connecting with friends, loved ones and your community via social media, phone, video or text can help reduce feelings of social isolation. Eating well, exercising daily and <a href="https://www.sleepfoundation.org/articles/how-much-sleep-do-we-really-need">getting enough sleep</a> are important for health and coping. </p>
<p>Be deliberate in making time to care for yourself by engaging in activities that bring you joy. Don’t be afraid to ask for help or to seek resources including counseling or therapy if you are feeling stressed. Practice positive self-talk by saying phrases out loud such as “This is temporary” and “We can do this.”</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p>
<p>The reality is that you do not want this virus. More than <a href="https://coronavirus.jhu.edu/map.html">a quarter million people with COVID-19 have died</a> in the U.S. We don’t yet know what the long-term effects will be or <a href="https://science.sciencemag.org/content/early/2020/10/13/science.abe5960">whether immunity after an infection will last</a>. Even young people who get it and recover can experience <a href="https://theconversation.com/im-a-covid-19-long-hauler-and-an-epidemiologist-heres-how-it-feels-when-symptoms-last-for-months-143676">continuing cognitive effects, fatigue</a> and potentially <a href="https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351">heart and lung damage</a>. As you look ahead, remember these important safety tips and find socially distanced activities that will help you remain connected and safe.</p>
<p><em>This story was updated Nov. 20 with the latest COVID-19 case and fatality data.</em></p><img src="https://counter.theconversation.com/content/146981/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melissa Burdi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Social distancing can get tougher in the fall and winter. These simple steps can help keep you and your loved ones healthy.Melissa Burdi, Dean, Purdue University Global School of Nursing, Purdue UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1436582020-09-09T12:37:42Z2020-09-09T12:37:42ZNurses are on the coronavirus frontline, so why are they being left out of the response?<p>More than 600 nurses worldwide have died from COVID-19 <a href="https://www.icn.ch/news/more-600-nurses-die-covid-19-worldwide">during the pandemic</a>. This should not be a surprise: we are the <a href="https://www.who.int/hrh/news/2017/NursingApril2017-2.pdf?ua=1">largest group of healthcare workers in the world</a>, dedicated to preventing the spread of coronavirus, and we are also engaged in caring for those who are suffering. </p>
<p>But although we are on the frontline of this crisis, nurses are too often being left out of responses to the pandemic. </p>
<h2>Uniquely at risk</h2>
<p>In the UK and other countries with high rates of coronavirus deaths, there are increasing inequalities in health outcomes for different income groups. In England and Wales, the mortality rates from COVID-19 in the most deprived areas are <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19bylocalareasanddeprivation/deathsoccurringbetween1marchand31may2020#:%7E:text=In%20England%2C%20the%20age%2Dstandardised,(58.8%20deaths%20per%20100%2C000">more than double the least deprived</a>. </p>
<p>In general, the risk of ill health increases for people who live on a low income. Common <a href="https://publichealthmatters.blog.gov.uk/2019/03/04/health-matters-ambitions-to-tackle-persisting-inequalities-in-cardiovascular-disease/#:%7E:text=Cardiovascular%20disease%3A%20A%20major%20cause%20of%20health%20inequalities&text=It%20is%20also%20one%20of,in%20the%20least%20deprived%20area">health issues</a> that affect these groups include high blood pressure, coronary heart disease, lung disease, type 2 diabetes and obesity. All of these put people at higher risk of becoming sicker and dying from COVID-19. Death rates are <a href="https://theconversation.com/why-are-black-and-asian-people-at-greater-risk-of-coronavirus-heres-what-we-found-140584">highest</a> among people from Black, Asian and minority ethnic backgrounds. </p>
<p>These communities are also disproportionately <a href="https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article#:%7E:text=Among%20all%20staff%20employed%20by,in%20the%20same%20staff%20groups">represented among nursing staff</a> some of whom are <a href="https://www.huffingtonpost.co.uk/entry/nurses-generations-reveal-realities-low-pay-nhs_uk_595de3b3e4b02e9bdb0a40c2">living on the lowest wages</a>. </p>
<h2>Lacking equipment</h2>
<p>Nurses working in hospitals, care homes and within communities are often put at greater risk from COVID-19 because they have not been given adequate personal protective equipment, or PPE. </p>
<p>A <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30164-X/fulltext#seccestitle70">study</a> of nearly 100,000 health workers in the UK and US found that people working on the frontline of the coronavirus pandemic were three times more likely to test positive for the disease than the general community. Health workers from a Black, Asian or minority ethnic background were found to be five times more likely to test positive than white people who did not work in healthcare. Workers who reported a lack of adequate PPE in their healthcare institutions were at greater risk still. </p>
<p>Another <a href="https://www.rcn.org.uk/news-and-events/news/uk-bame-nursing-staff-experiencing-greater-ppe-shortages-covid-19-280520">study</a> by the UK’s Royal College of Nursing, meanwhile, found that more than half of Black, Asian and minority ethnic respondents have felt pressure to work without the correct PPE compared to just over a third of other respondents. These groups were also asked to reuse PPE more frequently than their white counterparts. </p>
<h2>Denied a voice</h2>
<p>It’s a painful irony that as nurses battle against the coronavirus pandemic, 2020 is the World Health Organization’s <a href="https://www.who.int/campaigns/year-of-the-nurse-and-the-midwife-2020">Year of the Nurse and Midwife</a> which was supposed to raise the profile and perceptions of nurses globally. </p>
<p>But the response to the pandemic in the UK has starkly shown that our expertise and experience as a profession is not being called upon and our potential is not recognised. We are the biggest work force for health in the UK working in hospitals, care homes and community settings to care for those with COVID-19 and help prevent its spread yet we have no representation on the official <a href="https://www.gov.uk/government/publications/scientific-advisory-group-for-emergencies-sage-coronavirus-covid-19-response-membership/list-of-participants-of-sage-and-related-sub-groups">scientific advisory group</a> (SAGE), which advises the government on its coronavirus response. Nor are we represented on the rival <a href="https://www.independentsage.org/who-is-on-the-independent-sage/">Independent SAGE</a> group.</p>
<p>Our role in policy development and planning is negligible despite the invaluable insights our unique position in health systems gives us. Our lack of representation and reward means that we are also suffering from the impacts of inequalities along with those we care for. </p>
<p>Given the chance, nurses could help guide coronavirus policy in a number of ways. First, by being a witness to the health impacts of COVID-19 on our local communities and staff, recording and researching inequity of access to services. Second, we can advise on how to provide prevention and treatment resources to those most at risk. Finally, we can set a positive example in terms of equality of opportunity, fair working conditions, protection from infection and pay. This could start with ensuring equal provision of PPE for all staff.</p>
<p>Nurses are at the forefront of trying to reduce existing health inequalities which are being made worse by COVID-19. We are also victims of those inequalities – a feminised, racialised workforce dealing with poor conditions and lacking a political voice. Care and prevention of disease are not perceived as being as important as finding a cure or a vaccine, but in the global recovery from COVID-19, all these elements are equally vital. </p>
<p>We have already lost too many colleagues in the fight against this disease. It’s time our work is recognised and we are given an official voice to help us all recover from the coronavirus pandemic.</p><img src="https://counter.theconversation.com/content/143658/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ann Hemingway is a Registered Nurse and has a PhD.</span></em></p>Nurses are uniquely at risk of COVID-19, and are affected by many of the health inequalities that the pandemic has exposed. But no one is listening to them.Ann Hemingway, Professor of Public Health, Bournemouth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1447932020-08-25T12:24:11Z2020-08-25T12:24:11ZSchool nurses should be leading the COVID-19 response, but many schools don’t have one<figure><img src="https://images.theconversation.com/files/354185/original/file-20200821-20-1wfjc2q.jpg?ixlib=rb-1.1.0&rect=15%2C7%2C2532%2C1692&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The CDC recommends schools have one nurse for every 750 students. Only about 40% of schools meet that bar.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/photos/covid-screening-school?family=creative&license=rf&phrase=covid%20screening%20school&sort=best">Istock/Getty Images</a></span></figcaption></figure><figure class="align-center ">
<img alt="Significant figure: 25% of U.S. schools don't employ a school nurse." src="https://images.theconversation.com/files/354189/original/file-20200821-24-fu9grf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354189/original/file-20200821-24-fu9grf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354189/original/file-20200821-24-fu9grf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354189/original/file-20200821-24-fu9grf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354189/original/file-20200821-24-fu9grf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354189/original/file-20200821-24-fu9grf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354189/original/file-20200821-24-fu9grf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="source" href="https://schoolnursenet.nasn.org/blogs/nasn-profile/2017/05/10/school-nurse-workforce-study-results">National Association of School Nurses</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>In schools trying to hold in-person classes this fall, students and staff will be looking to one person for guidance with the coronavirus pandemic: the school nurse. </p>
<p>Many schools won’t have one. In those that do, the nurse’s responsibilities are quickly expanding.</p>
<p>Daily screenings for COVID-19 symptoms, assessing illnesses and isolating sick kids are adding to their already heavy work loads as they attend to hundreds of students and staff. </p>
<p>I am a <a href="https://www.purdue.edu/hhs/nur/directory/faculty/sorg_meg.html">professor of pediatric nursing</a>, and I formerly worked as a pediatric nurse practitioner in a school-based clinic. I recognize the tremendous stress school nurses are facing right now as they navigate getting students back to school safely in the midst of a pandemic.</p>
<h2>A quarter of US schools don’t have a nurse</h2>
<p>Prior to the pandemic, many school nurses were already overwhelmed.</p>
<p>The CDC recommends schools have <a href="https://www.cdc.gov/healthyschools/professional_development/e-learning/shg/page13.html">one nurse for every 750 students</a>; however, only <a href="https://schoolnursenet.nasn.org/blogs/nasn-profile/2017/05/10/school-nurse-workforce-study-results">around 40%</a> of school districts in the United States actually meet this recommendation, according to the National Association of School Nurses. </p>
<p>Many districts have only one nurse shared between multiple schools. A full quarter of schools <a href="https://schoolnursenet.nasn.org/blogs/nasn-profile/2017/05/10/school-nurse-workforce-study-results">have no nurse at all</a>.</p>
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<h2>Nurses’ new roles amid COVID-19</h2>
<p>School nurses play a critical role in child health maintenance that is key to keeping children in the classroom. As greater numbers of children with complex medical needs enter mainstream schools, school nurses increasingly have been tasked with providing more complicated care. </p>
<p>Now, in addition to their <a href="https://doi.org/10.1542/peds.2008-0382">regular duties</a> of ensuring students’ immunizations are current, administering medications, and tending to injuries during school hours, many nurses are also responsible for screening students for COVID-19 symptoms, following the latest <a href="https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html">updates and advice</a> about the virus, and helping decide whether or not a child should remain at school.</p>
<p>Often, they’re working out of small offices with little room for social distancing. Those conditions may have been manageable before, but today, the tight spaces can increase their risk of infection as children suspected of having the virus are sent to the nurse for help.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Some nurses are expressing frustration with the lack of resources and with school plans that they say put students and staff at risk.</p>
<p>One Georgia nurse <a href="https://www.washingtonpost.com/outlook/school-nurse-unsafe-reopening/2020/08/14/92011c48-dd84-11ea-8051-d5f887d73381_story.html">wrote that she quit</a> because she feared her district’s plan likely meant she would get infected and unknowingly spread the virus to students, their families and her own. Others have raised concerns with their districts’ move to return students to classrooms, rather than continuing online learning, while the <a href="https://www.npr.org/2020/07/31/896767422/overwhelmed-stressed-scared-school-nurses-brace-for-the-fall-semester">community infection rate is still high</a>.</p>
<p>When schools do shift to online learning, that doesn’t necessarily mean the nurse’s job ends. While <a href="https://www.wptv.com/news/region-c-palm-beach-county/140-school-nurses-health-technicians-furloughed-in-palm-beach-county">some districts are furloughing nurses</a> during virtual learning, nurses in others have <a href="https://www.nytimes.com/2020/08/20/us/schools-reopening-nurses-covid.html">continued connecting with students</a> and working on immunization plans at a time when doctors’ office closures may have put children behind on their shots.</p><img src="https://counter.theconversation.com/content/144793/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Meg Sorg does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>School nurses were already overwhelmed, with hundreds of students and staff in their charge. Now, COVID-19 screenings and testing have become their priority.Meg Sorg, Clinical Assistant Professor of Nursing, Purdue UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1379752020-07-07T21:11:29Z2020-07-07T21:11:29ZSimulations with actors prepare nurses for the demands of their profession<figure><img src="https://images.theconversation.com/files/345342/original/file-20200702-111374-1drboia.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3000%2C1957&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Training with actors gives nurses the chance to practise caring for a diverse set of patients.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span></figcaption></figure><p>Now more than ever, it is essential that post-secondary nursing programs train students to deal with real-world scenarios. The sudden onset of COVID-19 has further highlighted the critical role nurses play in our health system. What role can professional actors play in preparing nursing students to handle these demands? </p>
<p>At MacEwan University, our nursing science program uses theatre graduates to play standardized patients in clinical simulations. In a typical simulation, the instructor asks the actor to improvise a situation that the nursing students may face in their professional practice. After each simulation, the instructor leads a debriefing session to help nursing students reflect on what worked and what they can improve on.</p>
<h2>Benefits of using actors</h2>
<p>According to Cynthia Gundermann, who co-ordinates theatre graduates in the simulation program, her students benefit greatly from working with the actors. “When our learners can suspend their disbelief and fully engage with the portrayed characters, they are able to gain richer and more meaningful learning from their simulation events.” </p>
<p>To help the students buy into the simulations, the actors use <a href="https://www.penguinrandomhouse.com/books/350929/the-stanislavski-system-by-sonia-moore/">Russian theatre actor Constantin Stanislavski’s psychological realism techniques</a> to create believable patients. “The most important thing is to be authentic,” explained theatre graduate Dempsey Bolton. “Working with actors is the closest students can get to a real-world situation.” </p>
<p>Research demonstrates that role-play with actors enhances the realism of clinical simulations. <a href="https://doi.org/10.1016/j.pec.2014.07.001">One study conducted with the Program to Enhance Relational and Communication Skills (PERCS)</a> noted that 98 per cent of 192 learners and 97 per cent of 33 faculty members described the actors’ portrayals of patients as realistic. In addition, 97 per cent of learners and 100 per cent of faculty agreed that the use of actors was valuable to learning.</p>
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Read more:
<a href="https://theconversation.com/how-theatre-training-can-boost-your-doctors-empathy-102395">How theatre training can boost your doctor's empathy</a>
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<p>The actors also use renowned acting teacher <a href="http://applausebooks.com/books/9781617746192">Stella Adler’s theories</a> on character development to portray patients with a wide range of physical, psychological and socioeconomic characteristics. This helps the students better understand how to treat patients with diverse worldviews, backgrounds and prejudices. Theatre graduate Jarrod Smith said exploring patients’ backstories helps him “put flesh on their bones,” resulting in more truthful performances. “I want to know what my characters ate for lunch,” said Smith jokingly.</p>
<p>In addition, the actors draw on American theatre coach <a href="https://www.penguinrandomhouse.com/books/113022/sanford-meisner-on-acting-by-sanford-meisner-and-dennis-longwell-with-an-introduction-by-sydney-pollack/">Sanford Meisner’s</a> listening and improvisation exercises to interact with nursing students without the need for a scripted text. This helps students develop communications skills and the ability to think on their feet. Similarly, <a href="https://doi.org/10.1016/j.pec.2014.07.001">research by Sigall K. Bell and others found that learners valued the actors’ flexibility in their approach to conversation.</a></p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345414/original/file-20200703-33926-jussgf.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Simulations with actors train nurses to deal with a host of real-world scenarios.</span>
<span class="attribution"><span class="source">(Unsplash/CDC)</span></span>
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<p>The actors also use <a href="https://www.wiley.com/en-ca/Respect+for+Acting%2C+2nd+Edition-p-9780470228487">techniques developed by Uta Hagen</a> to realistically express intense emotions such as grief, fear, anxiety, sadness and anger. Interacting with patients in emotional distress helps nursing student develop empathy and teaches them to balance both the patient’s physical and psychological needs. </p>
<p>Nursing instructors like working with actors because they are able to instantly incorporate feedback in simulations, just as they would a theatre director’s notes in rehearsals. “In theatre school we were encouraged to embrace constructive criticism just as much as praise,” said graduate Kendra Sargeant. “When a director gives me a note, I’m able to integrate it into my performance immediately.” </p>
<p>The use of professional actors in simulations does not only benefit the nursing students. “It’s a beneficial relationship on both ends,” said Smith. “It’s an opportunity to dust off my acting chops between shows.” Working in simulations also gives Smith a sense of purpose, knowing he is contributing to society in a positive way. “It’s rewarding know that you’re helping someone who’s going to be a nurse one day.” </p>
<h2>Challenges of simulation work</h2>
<p>While performing in simulations is gratifying, the actors experience a few challenges. It can be difficult to maintain a sense of spontaneity when acting the same scenario repeatedly, albeit for different students. “Keeping it fresh is definitely a challenge,” said Bolton. </p>
<p>In addition, Sargeant confessed that the repetitive nature of the work can be emotionally taxing. Smith agreed: “Going to extreme emotional places throughout an eight hour day can be pretty draining.” Research indicates that some actors <a href="http://dx.doi.org/10.1016/j.ecns.2016.08.005">depicting mental illnesses, such as depression, have difficulty shaking off such feelings, even days after the simulations</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345585/original/file-20200703-33956-7tnow9.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A mannequin being used for a surgery simulation.</span>
<span class="attribution"><span class="source">(Unsplash/Tim Cooper)</span></span>
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</figure>
<p>Another challenge is that sometimes the actors are required to act opposite a mannequin. This can elicit understandable giggles from the nursing students. Therefore the actors must rely on their acting chops to help them treat the mannequin as if it were a real human being. “When we’re engaged, it’s easier for the students to be engaged,” said Smith. </p>
<p>This fledgling partnership between MacEwan’s theatre graduates and nursing students has highlighted the striking similarity between the roles of actors and nurses. Both jobs are about being present, listening, thinking on your feet, understanding people, managing intense emotions, working as part of a team, embracing constructive criticism, navigating personal boundaries, fostering empathy and acting authentically. And perhaps most important, both jobs keep us alive — one physically and one spiritually.</p><img src="https://counter.theconversation.com/content/137975/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Using actors can provide nurses with valuable training dealing with a diverse set of patients.Dawn Sadoway, Assistant Professor, Theatre Department, MacEwan UniversityLeigh Rivenbark, Assistant Professor, Theatre Department, MacEwan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1403202020-06-24T08:23:05Z2020-06-24T08:23:05ZCoronavirus, nursing and war: action that followed national conflict can help guide the UK now<p>The language of war is often used around COVID-19. While this is <a href="https://rcni.com/nursing-standard/opinion/comment/covid-19-why-we-need-to-ditch-military-terms-160071">often decried as unhelpful</a>, in the field of nursing there are in fact similarities.</p>
<p>When the second word war began, the UK had a massive shortage of nurses, which led to a surge in recruitment of an <a href="https://books.google.co.uk/books?id=GZGKAgAAQBAJ&lpg=PA284&dq=Rafferty%2C%20AM%20%2CThe%20Politics%20of%20Nursing%20Knowledge%E2%80%99&pg=PP1#v=onepage&q=Rafferty,%20AM%20,The%20Politics%20of%20Nursing%20Knowledge%E2%80%99&f=false">extra 30,000-70,000</a> to deal with air raid casualties. The country was also short of some <a href="https://www.health.org.uk/news-and-comment/news/a-quarter-of-all-nursing-students-are-dropping-out-of-their-degrees">40,000 nurses</a> before the current coronavirus outbreak. This is only counting vacancies, and is not a calculation of population-based demand.</p>
<p>Increasing the number of nurses today has been possible through the emergency COVID-19 legislation and the establishment of a <a href="https://www.nmc.org.uk/news/coronavirus/temporary-registration/">temporary register by the Nursing and Midwifery Council</a>. Essentially, this has meant calling upon nursing reserves, replicating a strategy used in the war.</p>
<p>The war effort permanently changed the UK’s nursing provision for the better. If there is to be any parallel today, we need to plan what the next steps in nursing policy might be – to build on the best of what the pandemic has brought. </p>
<h2>The outcomes of the 1940s</h2>
<p>During WWII, a Control of Engagement Order was used to help deploy nurses and trainees aged 18-40 to areas of need. It was supported by a Civil Nursing Reserve, <a href="https://books.google.co.uk/books?id=GZGKAgAAQBAJ&lpg=PA284&dq=Rafferty%2C%20AM%20%2CThe%20Politics%20of%20Nursing%20Knowledge%E2%80%99&pg=PP1#v=onepage&q=Rafferty%2C%20AM%20%2CThe%20Politics%20of%20Nursing%20Knowledge%E2%80%99&f=false">made up of women who weren’t nurses</a> but who had previous training and experience together with untrained volunteers, known as nursing auxiliaries.</p>
<p>An important discovery from surveys at the time was the extent to which the problems of nursing supply were not just of quantity and quality, but also of distribution. The Ministry of Health learned that if it was to direct nurses to hospitals where they were needed, it was going to have to rationalise payments for nurses and those organised through the Civil Nursing Reserve. This led to <a href="https://books.google.co.uk/books?id=GZGKAgAAQBAJ&lpg=PA284&dq=Rafferty%2C%20AM%20%2CThe%20Politics%20of%20Nursing%20Knowledge%E2%80%99&pg=PP1#v=onepage&q=Rafferty%2C%20AM%20%2CThe%20Politics%20of%20Nursing%20Knowledge%E2%80%99&f=false">standardised rates</a> that were in excess of those previously offered by hospitals.</p>
<p>The financial implications of these deepened the government’s involvement in sustaining the running costs of the hospital service. This increased commitment and added momentum to establishing the NHS.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/342245/original/file-20200616-23221-1rnlyu9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/342245/original/file-20200616-23221-1rnlyu9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=634&fit=crop&dpr=1 600w, https://images.theconversation.com/files/342245/original/file-20200616-23221-1rnlyu9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=634&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/342245/original/file-20200616-23221-1rnlyu9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=634&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/342245/original/file-20200616-23221-1rnlyu9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=797&fit=crop&dpr=1 754w, https://images.theconversation.com/files/342245/original/file-20200616-23221-1rnlyu9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=797&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/342245/original/file-20200616-23221-1rnlyu9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=797&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Volunteer nursing capacity continued after the war in the form of the Civil Defence Corps.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/f/f6/Student_Nurse-_Life_at_St_Helier_Hospital%2C_Carshalton%2C_Surrey%2C_1943_D13877.jpg">Wikimedia Commons</a></span>
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<p>Wars and pandemics reveal the fault lines in our society. As with the first world war, the demands made on citizens during WWII prompted consideration of the kind of society that should be constructed afterwards. Many of the emergency arrangements became permanent fixtures in the postwar welfare state. </p>
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<img alt="" src="https://images.theconversation.com/files/339451/original/file-20200603-130917-1phwlgk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339451/original/file-20200603-130917-1phwlgk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=150&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339451/original/file-20200603-130917-1phwlgk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=150&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339451/original/file-20200603-130917-1phwlgk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=150&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339451/original/file-20200603-130917-1phwlgk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=189&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339451/original/file-20200603-130917-1phwlgk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=189&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339451/original/file-20200603-130917-1phwlgk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=189&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>Listen to Recovery, a series from <a href="https://theconversation.com/uk/topics/the-anthill-podcast-27460">The Anthill Podcast</a>, to hear more about how the world recovered from past crises, including an episode on the <a href="https://theconversation.com/how-the-shock-of-the-second-world-war-transformed-the-british-state-recovery-podcast-part-four-141324">recovery after the second world war in Britain</a>.</em></p>
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<h2>How to improve nursing today</h2>
<p>The UK started the pandemic with no reserve capacity, but have rapidly tried to create some headroom via the temporary register. This has been achieved by returning <a href="https://www.independent.co.uk/news/uk/politics/coronavirus-latest-retired-nhs-workers-staff-return-boris-johnson-a9433001.html">20,000 nurses from recent retirement</a>. The gap has also been plugged by offering <a href="https://www.nmc.org.uk/news/coronavirus/information-for-students-and-educators/">clinical placements</a> to second- and third-year student nurses and midwives. Just under 20,000 students were deployed, Higher Education England has said. </p>
<p>Given the shortage before the pandemic, it is worth considering how to incentivise those who have volunteered their services to continue afterwards. Relying on appeals to patriotism will not wash. </p>
<p>The prime minister’s own experience of nursing care has resulted in him expressing his heartfelt gratitude to the two nurses who provided surveillance and oversaw his care. The key will be to ensure that such fulsome praise and appreciation of nurses’ skills translates now into a well-structured and remunerated pay system. Actions that appear to take for granted the efforts of those who worked through the crisis – including students – need to be avoided. </p>
<p>There also needs to be a clear career structure and opportunities for progression that builds nursing leadership to support nurses to stay in the profession. This is where the greatest gain and return on investment can be made. Echoing the recommendations from WHO’s recent <a href="https://www.who.int/publications/i/item/nursing-report-2020">State of the World’s Nursing Report</a>, we need a massive investment in education – including continuing education for qualified nurses – decent jobs and leadership at all levels. </p>
<p>Equally important is creating a proper reserve of nurses – trained in public and population health – for responding to future pandemics. My mother, who was a nurse, was a member of the <a href="http://civildefenceassociation.uk/history/">Civil Defence Corps</a> (CDC) after the war, which trained volunteers in community emergency preparedness. Perhaps the spirit and substance of the CDC can be recreated to create a citizen volunteer force trained in emergency preparedness that could mobilise in the aftermath of a future national crisis. Citizen participation in emergency preparedness is central in <a href="https://www.ft.com/content/72b07710-69f5-11ea-a3c9-1fe6fedcca75">some countries</a>, such as <a href="https://ec.europa.eu/echo/sites/echo-site/files/peer_review_finland.pdf#page=%5B15%5D">Finland</a>. Having something similar could build resilience into our health system so that it can respond to future shocks.</p>
<h2>Warnings from history</h2>
<p>Although direction of nursing labour during the war proved controversial, it helped to secure supply at hotspots of need. In the process, however, it <a href="https://doi.org/10.4324/9780203403310">depleted areas that were short of staff before the war</a>. </p>
<p>TB sanatora, chronic diseases, mental health and midwifery were all areas that felt the implications of labour shortages. With unmet need, there was <a href="https://books.google.co.uk/books?id=GZGKAgAAQBAJ&lpg=PA284&dq=Rafferty%2C%20AM%20%2CThe%20Politics%20of%20Nursing%20Knowledge%E2%80%99&pg=PP1#v=onepage&q=Rafferty%2C%20AM%20%2CThe%20Politics%20of%20Nursing%20Knowledge%E2%80%99&f=false">rising morbidity</a> in these areas when the NHS was established. </p>
<p>One other, major difference between the 1940s and today is the attention given to mental health. The crisis is having an affect not only the population but on health workers themselves – and on an unprecedented scale.</p>
<p>With some exceptions, there was scant recognition of the mental health fallout for the population and health workers after WWII. Today, investment is needed in building support of many different kinds on a scale hitherto unimaginable.</p>
<p>This is our moment. We must use the heightened value of nursing to craft positive policies and investment that will secure frontline care for the future.</p><img src="https://counter.theconversation.com/content/140320/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anne Marie Rafferty is president of the Royal College of Nursing, UK and co-director of the NIHR Health and Social Care Workforce Research Centre. </span></em></p>Comparisons with the second world war are usually unhelpful – but the crisis changed UK nursing for the better. The pandemic offers a similar chance to rethink nursing is provided.Anne Marie Rafferty, Professor of Nursing Policy, King's College LondonLicensed as Creative Commons – attribution, no derivatives.