The reality behind nursing numbers

Dr Christine O’Malley

Dr Christine O’Malley challenges the view that the Irish
health sector employs too many nurses

Ireland has more nurses than France.” It was 10 or more years ago, and I was asked for a comment on whether Ireland has an excess of nurses. I don’t remember what I said, but I didn’t think about it too much. It was obvious the wards were under-staffed.
But the question kept cropping up. Somehow, the OECD figure for nurses in Ireland took on a meaning. Politicians and economists used it to say the public system was over-staffed, inefficient. There was pressure to reduce nursing numbers on hospital wards. It was weird, and worrying too.
One day, I looked at the OECD website and found that the figure derives from the nursing register. So that’s fine. Who cares how many nurses are on the register? It’s nothing to do with staffing levels in the hospitals.
I wrote about it. I met Leo Varadkar at the IMO AGM, when he was Minister for Health, and I said it to him. Looking back, I’m pretty sure he was not convinced. You see, in the meantime, the OECD had clarified that they don’t just take the figures from the register; they use CSO figures too. Only ‘professionally active’ nurses are counted.
By this time, we were well into the era of austerity. The public sector was being downsized. A generation of experienced nurses left and were not replaced. But the population of Ireland was climbing — 4.7 million at the last census. At this stage, hospitals were short of staff but more and more patients poured in.
One day stands out for me. A ward of 30 beds was supposed to have seven nurses. Instead, there were 33 patients and only four nurses. The nurses on duty, my professional colleagues, were distressed to the point of tears. It’s not just the nurses who suffer in that situation; it’s the patients.
Now there’s a nurses’ strike, and it’s partly because of staffing levels. But guess what? Ireland has too many nurses. That’s according to a detailed analysis in the Sunday Business Post, and Marian Finucane raised the same issue.

A ward of 30 beds was supposed to have seven nurses. Instead, there were 33 patients and only four nurses. The nurses on duty, my professional colleagues, were distressed to the point of tears

So I did a bit of maths. The OECD says Ireland has 11.6 ‘professionally active’ nurses per thousand population, way above the EU average of 8.4. For our population, that’s nearly 55,000 nurses.
But hold it right there! In November, the HSE said it employs 37,525 nurses, which is only 8.0 per thousand. That’s below the EU average. Instead of too many nurses, it’s the opposite. There aren’t enough to look after patients safely. No wonder the nurses are on strike.
I decided to work out where the 55,000 ‘professionally active’ nurses might be working. The OECD number should have excluded midwives and nurse managers. That brings it down a bit. Twenty or more private hospitals would account for some thousand. But there’s still a big gap.
I thought back to Nenagh Hospital. Years ago, I decided to learn about ‘nursing WTEs’, as it was a constant row with HSE management. Here’s the simple version. The HSE does not regard us as people. We are WTEs — whole-time equivalents. A full-time nurse is one WTE. But consider a nurse who works half-time hours, and has two colleagues who work a quarter week each. Those three individuals add-up to just one WTE.
Lots of nurses work part-time. To fill 100 posts, Nenagh Hospital needs about 135 people. If that is replicated across the public system, the HSE may be employing around 50,000 nurses.
Eureka!
Unfortunately, once a myth takes hold, it’s really hard to dislodge it, especially a silent, unspoken belief. Doctors and nurses live in the real world of patients. We know when there aren’t enough nurses in the clinics, wards and theatres. In contrast, HSE managers are mostly in offices; they rely on numbers. I believe this rubbish about OECD figures is why public hospital wards have been stripped of nurses. And when the HSE talks of changing the ‘skill-mix’ by adding valuable healthcare assistants, unfortunately they mean for them to be hired instead of fully-trained nurses.
I told some doctors my OECD explanation. They said the HSE doesn’t want to know, that if it suited them, they’d know. I disagree. I believe the answer is much more scary. They don’t know this stuff. Try asking how many ‘professionally active’ nurses the HSE employs. I’m guessing the answer is: They don’t know.
I was having my hair cut, and telling Suzie the story about ‘too many nurses’ in Ireland. “That’s mad,” she said, “Everyone knows how hard nurses work.” Like most people in Ireland, Suzie has visited family and friends in hospital, and she’s seen nurses on the job.
I said individual managers know there are too few nurses, but as an organisation, the HSE is blind.
‘Should’ve gone to Specsavers!’ said Suzie.

Eureka!
Unfortunately, once a myth takes hold, it’s really hard to dislodge it, especially a silent, unspoken belief. Doctors and nurses live in the real world of patients. We know when there aren’t enough nurses in the clinics, wards and theatres. In contrast, HSE managers are mostly in offices; they rely on numbers. I believe this rubbish about OECD figures is why public hospital wards have been stripped of nurses. And when the HSE talks of changing the ‘skill-mix’ by adding valuable healthcare assistants, unfortunately they mean for them to be hired instead of fully-trained nurses.
I told some doctors my OECD explanation. They said the HSE doesn’t want to know, that if it suited them, they’d know. I disagree. I believe the answer is much more scary. They don’t know this stuff. Try asking how many ‘professionally active’ nurses the HSE employs. I’m guessing the answer is: They don’t know.
I was having my hair cut, and telling Suzie the story about ‘too many nurses’ in Ireland. “That’s mad,” she said, “Everyone knows how hard nurses work.” Like most people in Ireland, Suzie has visited family and friends in hospital, and she’s seen nurses on the job.
I said individual managers know there are too few nurses, but as an organisation, the HSE is blind.
‘Should’ve gone to Specsavers!’ said Suzie.