Statistics skew nurse numbers and mask real shortage in hospitals

The nurses are going on strike and one of their grievances is poor staffing levels. But there’s a serious question hovering out there: are there too many nurses in Ireland? If so, that’s a significant contradiction, and the Health Service Executive would be right to stand firm. If the nurses are correct, there are real implications for patients.

This is not a new issue; it’s been around for years.

It all started with the OECD. It says Ireland has 11.6 nurses per thousand of population, way ahead of the EU average of 8.4. And it has clarified that it doesn't just look at the Register of Nurses, their figures reflect "professionally active nurses". If the OECD is right, that's about 55,000 nurses, surely plenty to run the Irish health system.

But here’s a thought: where do these professionally active nurses work? No one has clarified this, so I’m going to presume it includes the private sector as well as the public system. Ireland has 20 or more private hospitals. I’ve never seen a published figure so I don’t know how many nurses they employ, but it surely must be some thousand. So that’s the first part of the solution to the puzzle. Nurses in Ireland don’t all work in the public system.

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But the nurse’s strike is not about the private sector, it’s all to do with the HSE. So now we have to distinguish between the person and the post. In the public sector, employees are not people and nurses are not nurses. We are all WTE – Whole Time Equivalents.

Below EU average

Consider a nurse who works half-time hours, and has two colleagues who each work a quarter of a working week. Those three individuals add up to just one nursing WTE. Yes, it’s very confusing. Three professionally active nurses make just one HSE “nurse”. The numbers of part-time staff add up quickly. Ask any nurse and they’ll explain that a lot of their colleagues work less than full hours. In a hospital I know, only half the nurses work full-time. Last year, the HSE said it employed 37,525 nursing WTE. As there are 4.7 million people in Ireland, that comes in at about eight nurses per thousand. But hold on a minute: that’s actually below the EU average.

The next question should be: how many professionally active nurses does that represent? Or to put it another way, how many part-timers does the HSE employ? I wonder if it knows. Despite all previous discussions on this subject, I’ve never seen a figure. Actually, I suspect they’re just as puzzled as everyone else.

How many part-timers does the HSE employ? I've never seen a figure

I think this is the key reason why the OECD total is so high, why Ireland seems to have too many nurses, even though it’s not true.

And there are consequences, for patients and staff. If the HSE believes it has too many nurses, maybe that’s why it keeps whittling away at staffing levels on hospital wards. It would also explain why it is so keen to change the “skill-mix” on the wards, by employing healthcare assistants (HCAs). Nurses tell me HCAs are very welcome as an addition to the ward team. Their enthusiasm turns to shock when I say that the HSE appears to have a different view. Instead of adding, it seems the plan is to replace nurses with HCAs.

I watched this happen in London, and it was not a happy experience. When I returned to Ireland as a consultant geriatrician, it was so much easier to do the job well, because Irish wards were staffed with high-quality, fully trained nurses.

Recruitment difficulty

What’s it really like in the hospitals? Are they genuinely short-staffed? Yes, they definitely are. It’s very distressing to see the HSE constantly driving down the number of nurses looking after patients on the wards. Of course, it’s partly because of difficulty recruiting nurses, but I believe there is an underlying, unspoken belief that the wards are, in fact, over-staffed.

It's very distressing to see the HSE constantly driving down the number of nurses looking after patients on the wards

The result? If there aren’t enough nurses for a few hours, or a day, or always, then work is constantly reprioritised. But which patient is not a priority? Under such pressure, mistakes can be made, patients may be overlooked or possibly even harmed. And that’s unforgiveable. Then to fill gaps in staffing on one ward, hospitals move nurses from another. Sure, it looks efficient on paper. But if a nurse is assigned to a ward for a couple of hours, don’t be surprised if you can’t discuss your relative’s condition. They won’t know the case well enough.

The old-fashioned way was that patients with surgical problems were on surgical wards, and patients with medical problems were on medical wards. Each ward had a stable team of nurses, with experience in those conditions and complications. It was a safer system. It was efficient too, not just on paper, but in patient care. Surely, that’s what we all want.

Nursing is a demanding job, made more difficult these days because public hospitals are full all the time. I don’t think Ireland has too many nurses. I believe our hospital wards are under-staffed and this is unsafe for patients and nurses alike. Maybe going on strike is the only way to fix it.

Christine O’Malley is a retired consultant at Nenagh General Hospital and past president of the Irish Medical Organisation