Retaining nurses in the NHS

Editor—Finlayson et al chronicled the problems affecting nursing and the environmental factors contributing to the current shortages.¹ Embedded in their story is, however, a crucial element of the problem. Evidence from the United States, Canada, and Germany has found that nurses spend time performing functions not related to their professional skills, such as cleaning rooms or moving food trays. Nurses also reported more pressure to take up management responsibility, taking them away from the direct care of patients.

This means that, although a shortage of professional nursing may exist, a shortage of nurses might not. Nurses spend much of their time doing things that should be delegated to others and not enough of their time doing what they are educated to do. This is inefficient and demoralising and accounts for at least some of the widespread job dissatisfaction in the profession. Thus far, policy responses have come in one of two forms: raising salaries (favoured in Canada) and increasing capacity in nursing education programmes (favoured in many jurisdictions).

Paying nurses more money may be just, but it will not by itself produce more nurses or make them more content with their working conditions once the transitory glow of the extra money dims. Increasing the supply of new nurses may turn out to be perversely ineffective if overall numbers grow, nurses perform even more non-nursing tasks, and system costs rise because highly trained people are used inefficiently.

The problem is not restricted to nursing. A recent systematic review reported that nurse practitioners can do what general practitioners typically do in a wide variety of settings.² In health care it has proved difficult to get the division of labour right, and the complex array of professions, regulatory and licensing bodies, and organisational structures renders rapid adaptation to changing circumstances difficult.

These realities show that we should not rush headlong towards solutions that leave some fundamental problems unaddressed. The first obligation to the health system and to nurses is to ensure that the nursing practice matches their skills. Only when nurses are allowed to withdraw from areas of non-nursing activity and do what they should be doing will we know the true extent of the nursing shortage—if it exists at all. Achieving a proper division of labour that respects and maximises professionals' competencies will make the healthcare system more effective and efficient. It will also create a better motivated and contented workforce.