
The human impact of having too few nurses - EndXA
https://digest.bps.org.uk/2019/07/03/the-price-of-austerity-new-observational-research-suggests-lower-nurse-patient-ratios-really-do-result-in-poorer-health-care-interactions/
======
mft_
Interesting; on the one hand, one could dismiss this as an 'in other news,
water is wet'-type of study, but such evidence is probably very helpful in the
overall debate around healthcare funding.

Another factor not mentioned here but which might be relevant, is that as long
as nursing is undervalued (particularly economically, but in less tangible
ways too) to the extent that the system is short of nurses, it is unlikely
that employers would able to choose pick and choose better nurses from those
available, and/or remove bad ones. It seems obvious from an organisational
perspective that nurse > no nurse, but there's a direct link (in my
experience) between the quality of care patients receive, and the
attitude/experience/quality of the individual nursing staff.

~~~
tomatocracy
One lesson might well be that the relative pay gap between senior nurses and
senior doctors is too big - i.e. senior doctors should be paid less / we
should employ fewer doctors and more nurses. But that's probably a very very
hard thing to actually do politically both in terms of internal hospital/NHS
politics and national politics.

There are strongly entrenched interests in the NHS which I suspect constrain
relative pay between professions and grades much more tightly than they
constrain absolute pay numbers.

~~~
opportune
In the US I typically receive very poor care from people with the title "Nurse
Practitioner" who are usually hired for the exact purpose of getting people to
do doctor-like work for cheaper. They are ok at dealing with very normal
conditions like the flu/cold, acute non-critical injuries, etc. (which you
honestly don't even need to get care for anyway) but not good at dealing with
issues outside of that

~~~
barry-cotter
There’s no evidence to suggest inferior results or standards of care from
nurse practitioners than primary care doctors.

COMPARISON OF PRIMARY CARE OUTCOMES OF NURSE PRACTITIONERS AND PHYSICIANS

[https://research.libraries.wsu.edu/xmlui/bitstream/handle/23...](https://research.libraries.wsu.edu/xmlui/bitstream/handle/2376/3781/K_Stidham_010083140.pdf?sequence=1)

> Relevant Research Findings There are two landmark studies on the quality of
> the primary care delivered by nurse practitioners in regards to that of
> physicians. The first was by Mundinger, et al. (2000) and a follow-up study
> by Lenz, Mundinger, Kane, Hopkins & Lin (2004).

...

> The results indicated tllat there were no significant differences in patient
> outconles regarding health status, physiologic test results or health status
> utilization. Patients seen by NPs did have a statistically significant, but
> not clinically significant lower diastolic blood pressure (82 vs. 85 mm Hg;
> p==.04).

...

> The outcomes compared were health status, utilization of health services,
> and satisfaction with health care. The investigators found no significant
> differences in outcomes between the two groups, one seen by MDs and the
> other seen by NPs. The only difference in the results is the average number
> of primary care visits during year two for each discipline

~~~
opportune
You left out a crucial sentence from the paragraph you cited:

> The study was a randomized double-blind trial to compare outcomes of
> patients assigned to either NPs or MDs for follow-up care after initial
> management at either an emergency department or urgent care clinic for
> asthma, diabetes, and/or hypertension.

This excludes what I originally meant to refer to, which is non-routine care.
I am fully confident that NPs can handle routine care, what I was asserting is
that they are (anecdotally) bad at handling more complex/infrequent issues

~~~
barry-cotter
Well if that’s what you were referring to I’d say the average NP would agree.
They’re not meant to handle non-routine care, they’re meant to kick that
upstairs to someone more qualified.

~~~
melinoe
The bigger issue this discussion is pointing to is how too much
power/status/etc is concentrated among physicians in healthcare. It's too
hierarchical. Not saying physicians are poor at their jobs, but there's very
little evidence, when any evidence has been collected, that when another type
of provider, with a different educational and training history, has moved into
roles previously occupied by physicians, that outcomes are any different.

So, for example, I doubt that if NPs were specifically trained in specialty
area X, you'd see any real differences. If we're going to do anecdotes, my
personal experiences have been that the care provided by NPs (or PAs) has not
been any different from physicians, even in relatively specialty areas I've
dealt with. In fact, in some ways the care was better because we weren't
trying to pressured into expensive procedures with absolutely zero scientific
evidence of improved outcomes (having a hammer makes everything a nail).

What seems to be going under the radar is that the vast majority of MD
programs are moving to 1.5 years or even less of academic training, with the
rest being a variety of clinical experiences and quick rotations. This is
fine, but what it means is that if you have a need for a provider in specialty
area X, there's little difference between an MD + 4 years of specialty
training, and something like a PA or NP + 6 years of training. We could get
into discussions about academic preparedness, but at that point you're making
a lot of assumptions averaging over individual variability, and ignoring
things like nurses often having a ton of very technical training in actual
physical technique.

I would love nothing more than for competition to open up dramatically in
healthcare in terms of access, training, provider, and administrator models.
This is happening to some extent now but it needs to be dramatically expanded.
I see very little empirical or logical reason to assume that 4 years of
general MD/DO training to something more specialized, is better than alternate
training trajectories. Many of the professions in healthcare, such as nurses,
PAs, pharmacists, psychologists, dentists, optometrists, etc. could be
dramatically increased in scope of care, and new roles created that don't even
exist currently, if there wasn't such territoriality and hierarchy in
healthcare. Costs are spiraling currently in part because of rent-seeking
problems. We've built our current system on a very dated set of stereotypes
and outmoded assumptions, and are paying for it.

------
rayiner
Nurses in the UK are relatively poorly paid:
[https://nursingnotes.co.uk/agenda-for-change-pay-
scales-2019...](https://nursingnotes.co.uk/agenda-for-change-pay-
scales-2019-2020). They start at Band 5, which is about 24,000 pounds
annually. That’s about $30,000 per year for a job that requires a three-year
university education. (Somewhere between an ADN and BSN in the US.) London
gets a 20% or so bump, so let’s say $36,000. A VA nurse in NYC starts at more
than double that, over $78,000:
[https://www.va.gov/OHRM/Pay/2019/LPS/NY.xls](https://www.va.gov/OHRM/Pay/2019/LPS/NY.xls).

~~~
eterm
It's too crude to compare salaries like that.

That said, it's true that nursing is relatively under-paid in the UK. Part of
that however is because the state is the largest employer of nurses which
keeps wages down but that in turn keeps the cost of healthcare down.

When your state only provides a minority of nursing then it has to pay higher
wages to compete with the profit-driven sector.

But it's crude to say "Nurses make less than half than in the US", because so
do software developers, but no-one's saying "think of the devs!".

~~~
tptacek
Why is it too crude to compare those salaries? The gulf between 30k and 78k is
enormous. The UK nurse certainly isn't making up all, or even most, of that
difference in government benefits.

~~~
krageon
Every salary in the US should be prefaced with "this sounds really high, but
to compensate if anything goes wrong you will literally live in the streets
forever". Thus, comparing a US salary to another country's salary should be
taken with a mountain of salt: In most other countries where you'd want to
live the height of the salary is modulated by the necessity of providing the
less fortunate a liveable existence, including potentially you.

~~~
tptacek
This is one of the special-est pleadings I've ever seen on HN. You might has
well have said the privilege of living in the shadow of Big Ben compensates UK
nurses. We are comparing financial transactions.

~~~
dnadler
The point (not very well communicated) is that the comparison is pre-tax when
it should be post-tax.

~~~
tptacek
Doesn't that make the difference even more stark?

~~~
dnadler
Yeah, I guess I should have said "post-tax and post-insurance/wellfare
parity". Though you're right, the US salary would have lower taxes and the
difference would look larger. I suppose the GP was weighting tail events quite
heavily. Comparing the distribution of financial outcomes accross countries,
given a certain salary would be very interesting.

------
EndXA
You can find the original study here (open access):
[https://qualitysafety.bmj.com/node/156220.full](https://qualitysafety.bmj.com/node/156220.full)

Abstract:

 _Background_ \- Existing evidence indicates that reducing nurse staffing
and/or skill mix adversely affects care quality. Nursing shortages may lead
managers to dilute nursing team skill mix, substituting assistant personnel
for registered nurses (RNs). However, no previous studies have described the
relationship between nurse staffing and staff–patient interactions.

 _Setting_ \- Six wards at two English National Health Service hospitals.

 _Methods_ \- We observed 238 hours of care (n=270 patients). Staff–patient
interactions were rated using the Quality of Interactions Schedule. RN,
healthcare assistant (HCA) and patient numbers were used to calculate patient-
to-staff ratios. Multilevel regression models explored the association between
staffing levels, skill mix and the chance of an interaction being rated as
‘negative’ quality, rate at which patients experienced interactions and total
amount of time patients spent interacting with staff per observed hour.

 _Results_ \- 10% of the 3076 observed interactions were rated as negative.
The odds of a negative interaction increased significantly as the number of
patients per RN increased (p=0.035, OR of 2.82 for ≥8 patients/RN compared
with >6 to <8 patients/RN). A similar pattern was observed for HCA staffing
but the relationship was not significant (p=0.056). When RN staffing was low,
the odds of a negative interaction increased with higher HCA staffing. Rate of
interactions per patient hour, but not total amount of interaction time, was
related to RN and HCA staffing levels.

 _Conclusion_ \- Low RN staffing levels are associated with changes in quality
and quantity of staff–patient interactions. When RN staffing is low, increases
in assistant staff levels are not associated with improved quality of
staff–patient interactions. Beneficial effects from adding assistant staff are
likely to be dependent on having sufficient RNs to supervise, limiting the
scope for substitution.

------
carapace
So obviously this comes down to cost.

> in the aftermath of austerity and with not enough staff to go round

Pay more, get more nurses.

Or you can trade-off nurses for less-good health care.

\- - - -

Just to show an "existence proof" of an alternate universe, there are two
_totally free_ hospitals in India. They have no billing desk because they do
not bill.

So how is it funded?

The people who work there and who support them financially believe that they
are literally working for God. It is as if a Christian was volunteering to
work at hospitals established by Jesus.

[https://en.wikipedia.org/wiki/Sri_Sathya_Sai_Super_Specialit...](https://en.wikipedia.org/wiki/Sri_Sathya_Sai_Super_Speciality_Hospital)

> The Sri Sathya Sai Institutes of Higher Medical Sciences also popularly
> known as Super Specialty Hospitals are tertiary health care hospitals
> established by Sri Sathya Sai Baba to provide patient care facilities to all
> irrespective of caste, class, creed, gender, religion or nationality totally
> free of charge.

~~~
markdown
> So how is it funded?

Actually it's funded by the billions of dollars donated to his charitable
trust.

> Just to show an "existence proof" of an alternate universe, there are two
> totally free hospitals in India. They have no billing desk because they do
> not bill.

That's not an alt universe, that's just free healthcare, just like in the UK,
Fiji, New Zealand, and numerous other nations.

~~~
carapace
I'm not sure what point you're making, and I don't want to be disagreeable,
but I would point out that those nations' healthcare systems are paid for by
taxes, not charitable donations.

To me it seems impressive and wonderful that people have been inspired to
contribute billions of dollars to support health care and clean drinking water
and other charitable good works.

------
esotericn
It beggars belief that such a topic is even up for debate.

We're at such a state of technological advancement now in a place like the UK
that we're essentially post scarcity. We need very few people any more to
provide the basic building blocks of life.

In such a scenario, what we should be doing is taking advantage of that fact
to distribute labour more appropriately - more hospital work, more social
work, more housing, etcetera.

Instead what we have is seemingly some sort of race to put half the population
on retail/delivery/general grunt work to please the whims of the other half,
who don't actually end up happy because they're working their arse off and
generally stressed by the lack of 'life infrastructure' as well.

How has this gone so wrong?

~~~
mattmanser
The successive governments have been utterly idiotic about it too for a long
time, even recently cutting nursing bursaries, constantly freezing pay, while
simultaneously claiming for the last two decades we need mass immigration for
the nursing shortage.

Scrap the high income cap on national insurance contributions and pay for the
nurses!

~~~
deogeo
> claiming for the last two decades we need mass immigration for the nursing
> shortage.

Which is particularly funny, as immigrants are usually claimed to not take
jobs from natives because they create demand, thus creating more jobs. Is
nursing supposed to be an exception?

~~~
drak0n1c
On the other hand wouldn’t mass immigration increase the load on healthcare,
thus exacerbating the shortage?

NHS is centrally planned, which explains some of the supply shortage and why
demand-driven supply arguments don’t apply.

------
scotty79
In Poland by the end of 2020 half of the nurses will be eligible to retire.

Not to mention that Poland already has low number of nurses for its
population.

If you want to study how bad it can be keep an eye on Poland.

------
stupidcar
Better pay and recruitment might help move the needle on the number of nurses
in the short to medium term, but long term, the demographic time-bomb in
western countries means they will never have enough nurses to care for their
entire aged population in the manner they do now. So either a lot of people
are going to get sick and die without anybody to care for them, or, one way or
another, nursing and healthcare is going to have to change to become more
efficient. That will mean it becomes a lot more impersonal, with much greater
use of mechanisation, automation and robotics.

I don't see this as being entirely a bad thing. While nurses and other
caregivers can be an important source of human contact for the sick and
elderly, caring and being cared for by another person can be an emotionally
and physically fraught and draining process. If we can build automated systems
that allow baseline physical and hygienic needs to be met, even for the
frailest and sickest people, I think that had to be good for the mental health
of both those needing care, as it will reduce their sense of being a burden,
and on the caregivers themselves, as they will be able to focus on the most
important quality-of-life issues instead of being stuck on a treadmill of
providing basic care.

~~~
tracker1
I would assume pay rates are relatively locked in and restricted under the
government health care program in the UK. Not sure if there's a general Nurses
union, but much like police, they may be legally unable to unionize or strike.

------
tomohawk
You can look at healthcare as a cost or as a benefit.

If you look at it as a cost, you will attempt to minimize it.

If you look at it as a benefit, you will attempt to maximize it.

The State looks at healthcare as a cost to be minimized. The State does not
get sick or need healthcare.

Likewise, employers also look at healthcare as a cost to be minimized, but
they do have some motivation to provide better quality insurance if they wish
to attract employees.

Only you, the potential patient, really care about the benefits side of
healthcare, and the quality of healthcare.

Health insurance has been screwed up by having the State and/or employers
provide it for decades. What is required is for people to be able to purchase
health insurance themselves just like they do any other kind of insurance.
That would be a start anyway.

------
anbop
Obviously? It’s like saying “reducing the number of hole diggers on your staff
reduces the number of holes they dug.” Almost all care in hospitals is
provided by nurses, doctors function like high level executives who drop in
for a few minutes every day to look at the dashboards.

------
dash2
At least give me a diff-in-diff, guys.

To be fair, they acknowledge their limitations and the fact that they can't
make a causal interpretation. (Bad hospitals -> nurses leave?) But why the
hell design the study this way?

~~~
mft_
How would you design it otherwise? An interventional study would presumably be
ideal, but probably impossible to achieve.

------
purplezooey
Too few nurses and too many share buybacks.

------
chvid
The UK has free public health care but maybe introducing a price for a doctors
or hospital visit would help lessen this problem?

One could introduce a fee of say 20 pound pr. visit. Something that is low
enough that anyone in UK could pay it but also high enough to remind people
that what they are consuming is finite resource.

~~~
pbhjpbhj
>Something that is low enough that anyone in UK could pay it //

The problem is with such things that they're regressive taxes. Rich people can
still afford to go to the doctors when they have a sniffle but poor people
will re-consider even when they have a life-threatening illness because £20 is
a months food bills for the poor person.

~~~
jquery
Your hypothetical poor person isn't just poor, they're suffering in extreme
poverty, and the system could be designed to accommodate them.

Tolls on a congested bridge are "regressive" but are practical and make sense.
We shouldn't structure society around what makes things less convenient for
the rich, _there just isn 't very many of them_ by definition. We should
structure society around what improves the lives of most people, within the
current realities that exists. This is the classic sin of envy where we'd
actually rather be worse off if the person we envied was also worse off.

Now maybe there are other reasons to avoid co-pays, such as higher death rates
in areas with co-pays. I'd be interested to see a study that demonstrated the
tradeoffs of co-pays.

~~~
SolaceQuantum
I don't feel comparing healthcare to tolls is that useful. Systems to
accomodate people based on economic need have a tendency to introduce more
costs and overhead which will reduce the efficiency that the system was
attempting to solve in the first place! This cannot be said for tolls.

~~~
jquery
I was comparing copays to tolls, not healthcare costs in general. Copays
should generally be small, bearable even for a minimum wage worker, perhaps
pegged to an hour of the local minimum wage.

------
JJMcJ
What happens with Brexit, with all the health care workers from the Continent?

Do they have to go home?

Special rules to allow them to stay?

------
Proven
There's never too few nurses, there's only not enough money to pay for
"enough" nurses

------
jimbob45
There is no shortage, my gf just finished nursing school and can't find a job
and many of her peers are in the same boat.

Hospitals don't want to hire nurses because it loses them money. They only
care about staying at the federally-mandated minimum staffing ratio, which
they can skirt by only staffing adequate numbers when the oversight agencies
come around. Seems like this is happening in every industry - CS appears to
not want to hire either unless they absolutely are forced to fill a void.
They'd rather just have one person do the work of two people since that person
won't be able to find a job elsewhere anyway.

~~~
phpnode
This article is about the UK where the NHS has been chronically underfunded
for the last decade.

~~~
isostatic
The NHS has been chronically underfunded for 40 years.

In 2007, before the crash, after 10 years of New Labour, the U.S. spent 15% of
its GDP on healthcare. German 10%, the Netherlands 9%.

The UK spent 7.4%.

In fact it's over the last 10 years that the UK has begun to catch up with the
rest of Europe.

[http://imgur.com/mUI9oWil.png](http://imgur.com/mUI9oWil.png)

~~~
barry-cotter
Life Expectancy at Birth

Netherlands 81.6

U.K. 81.2

Germany 81.1

USA 78.6

[https://data.oecd.org/healthstat/life-expectancy-at-
birth.ht...](https://data.oecd.org/healthstat/life-expectancy-at-birth.htm)

~~~
isostatic
Which just goes to show how superior the NHS is. It’s still underfunded
though.

