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Professor Linda Aiken is Director of the Centre for Health Outcomes and Policy Research, and Senior Fellow of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. 

She spoke at a recent Health Foundation event about how the US has tackled its nursing shortage over the last few decades, allowing nurses to provide the highest quality care while delivering better nurse satisfaction and retention. Her pioneering research has created an evidence base showing the importance of improving nurse work environments. We caught up with her to find out more. 

Over the past 20 years the US has solved its nursing shortage so that nursing is now considered a ‘number one career choice in the US’. How was that achieved and what can the UK learn?

We made nursing a more attractive profession in the US. We did that by improving staffing levels so that nurses had more time to spend with each patient, and by giving nurses more autonomy in their practice, and more involvement in hospital decision making. We also did a lot to reward nurses with higher education and created opportunities for career progression.

All those things together, plus increasing demand for nurses which drove up salary levels, helped to make nursing a career to aspire to. 

From your knowledge of the NHS, how are the nursing workforce challenges similar and also different to those the US faced?

Many of the issues we faced are the same as you face now. In the UK wages have been stagnant for a while, and the numbers clearly show there are just not enough nurses to take care of patients. It doesn’t matter how committed nurses are, it’s an overwhelming task. And that’s a major problem as there is now such a high burnout rate among nurses. 

The last big nursing shortage we had in the US was in the early 1980s when hospitals started being paid per admission no matter how long patients stayed in. It was clear that having more nurses kept the length of stay down. So that prompted US hospitals to create more nursing positions, and to realise that it wasn’t cost effective to rely on less qualified nursing assistant or associate roles. 

That’s kind of interesting as it’s the opposite direction to the way the NHS is going now, which is to introduce new categories of staff with less education and skills than a nurse. Our experience in the US is that doesn’t work. Nurses’ productivity goes up when they work with other nurses, and it goes down when there are too many people that require their supervision.

You have championed the idea of nurses each caring for fewer patients. Why is that so important to maintaining the nursing workforce?

A lot of research shows that nurses can only safely take care of so many patients at a time. So it makes sense to establish a floor below which staffing is not allowed to go because it’s unsafe. 

Many places around the world have done this or are now moving in this direction. Not just the US, but also Australia, Wales, Scotland and Ireland. 

A while ago NICE wanted to do the same in England, suggesting that nurses shouldn’t take care of more of eight patients each in an acute setting. Many nursing groups thought that was still too many and it wasn’t introduced. But a third of all NHS trusts were staffing below that standard. So if it had been adopted, a third of trusts would have had to improve their levels of staffing. 

It’s important because you can show that this variation in staffing across NHS trusts is what’s driving mortality. Where trusts are well staffed, their mortality is minimal. Nurse staffing levels also impact on other things, like readmissions, infections, and length of stay, which in turn impact on costs. 

Nurses are ‘value added’, especially in hospitals, because they prevent these expensive things from happening. Research clearly shows that the implications of not having enough nurses cost more than just employing more nurses. 

A key challenge for the NHS is increasing the number of nurses in training. What are the main solutions you would put forward?

One thing that’s changing everywhere is that a lot of university graduates are now interested in nursing. Job markets are changing and people want to try new careers.  Close to half of the applicants to university nursing programmes in the US already have a degree in another field. For those applicants, we’re offering an expedited university programme which means they can become a nurse in just 12-18 months. That is the most efficient way to train a nurse, so we’re welcoming them and doing everything we can to recruit them. 

In the UK, you’ve got university graduates wanting to go into nursing, but they already have student loans and there’s no bursary for nursing school, so it’s a huge financial commitment to do another full degree. You could see real progress in nurse supply by investing in training at postgraduate level, where you get fully-fledged nurses trained even faster than a nursing associate. These postgraduate nurses also tend to be very committed because they’re on their second career. 

What does creating a supportive working environment for nurses mean and what practical steps can local NHS leaders take?

Firstly, there’s a lot of inflexibility in the NHS about the shifts nurses are required to work, and that doesn’t take into account people’s life circumstances, such as having small children. In the US, we’ve developed all kinds of flexible working arrangements and part time jobs. For example, roles for nurses who only want to work weekends, or paying a higher amount for people who work only nights. 

Second, nurses need to feel that their expertise is respected and that they have a shared role in hospital decision-making. Nurses are the clinicians who spend the most time with patients, so they know what’s required to provide the best possible care. But right now, nobody is asking them. The majority of nurses say management doesn’t listen or respond to the problems that they identify in patient care.

How else do you think England can improve nursing as a career?

It raises the productivity of the whole system when everybody in that system is well educated, highly skilled and has room to progress. I was really looking forward to seeing a shift towards this in the new NHS Long Term Plan, but the indication is that it’s more of the same. Nurse practitioners are hardly mentioned, and instead it focuses on nursing associates and apprentice training. 

It’s essential to provide more opportunities for career progression that allow nurses to advance while still treating patients. 

Unlike the US, the UK has been very slow to adopt the idea of advanced nursing practice. However we’ve found that when you have more nurse practitioners in advanced roles: a) care improves, b) costs go down, and c) nurses have less burn out and more job satisfaction. 

I have been studying the UK for 25 years and your policies are always focused on solving the shortage for today, but in the meantime decades have gone by and the country is behind in adopting the long-term solutions that other countries have shown can work. Yes, you can rely on international nurses to a certain extent, but the long-term solution is really to encourage more people at home to pursue a career in nursing. And that’s about looking at the whole picture and thinking of all the ways to make nursing a more attractive job and career. 


This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.

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