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The effective training of nurses: manpower implications
In, J. Nurs. Stud., Vol. 22, No. 2. PP. 89-98, Printed m Great Britain
1985
t
0020-7489185 $3.00 + 0.00 1985 Pcrgamon Presc Lid
The effective training of nurses: manpower implications NORMAG.
REID, M.Sc., D.Phil., F.S.S. Director, Centre for Applied Health Studies, The University of Ulster, Coleraine BT52 ISA, Northern Ireland.
Abstract--In a period of scarce and shrinking resources, manpower planning is of great importance. One aspect of nurse manpower planning is to ensure that the clinical learning environment is adequate in terms of qualified nursing staff. A recent, detailed study of nurse training in the clinical area has highlighted the effects of manpower shortages in nurse education in the clinical area. It is argued that any further cuts in nurse manpower levels will have a direct, detrimental effect on the clinical learning environment, and this is illustrated by findings from the nurse training study. It is further suggested that the manpower problems of urban hospitals are often masked by discussion of manpower in terms of regional staffing levels.
There are three aspects of manpower planning which are of fundamental importance to the nursing profession: (a) that there are sufficient numbers of nurses in service to maintain acceptable standards of care; (b) that there are sufficient numbers of nurse educators and trained nurse practitioners to ensure an effective training for learner nurses; (c) that sufficient numbers of learners are training to maintain the service, given wastage rates of trained staff. These manpower considerations can lead to incompatible objectives. The nursing service, often under pressure through shortages of trained staff, may well be tempted to increase the ‘pairs of hands’ available to a ward by placing extra learners on the ward. This in turn may well lead to a poor educational experience for the learner because there are not enough trained staff to provide adequate supervision. The effective training of learners is a longterm investment in good standards of patient care, but this cannot be achieved at the expense of patient care in the present. 89
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If it is assumed that the present numbers of nurses, both trained and untrained, can deliver acceptable standards of patient care, two questions then arise: (i) Does the ratio of trained ward staff to learners ensure adequate supervision and training for the learners? (ii) Are we training enough nurses to ensure that sufficient numbers of nurses are maintained to deliver acceptable standards of care? Are we replacing nurses lost to the profession through wastage or retirement? A major research study, commissioned in 1979 by the Northern Ireland Council for Nurses and Midwives, and completed in 1983, addressed itself to question (i) above. This paper describes the main findings of that study and discusses the manpower implications of the findings. The method
The terms of reference of this study were ‘to examine the factors which determine the numbers of learners that a clinical area can effectively support’. The study was carried out over a four year period by a multi-disciplinary research team based in the Centre for Applied Health Studies, University of Ulster. Twenty-five wards, used for general medical experience for student nurses, were included in the study. The focus of the study was a 13-week allocation. A detailed evaluation of each ward as a learning environment was carried out. Wards were evaluated in terms of the quantity of relevant experience learners acquired, and in terms of the quality of that experience as reflected in the clinical performance of the learners. This evaluation revealed that there were two distinct groups of wards within the 25 studied, one group consisting of wards which were significantly better as learning environments than the other group. The criteria which distinguished between these two groups were then examined. For example, were the ‘better’ wards better staffed? Hundreds of different criteria were investigated including many aspects of ward activity which was identified through direct observation of ward work by the research team, indices like bed occupancy, staffing levels and patient turnover, organizational factors like the number of consultant rounds and a vast amount of attitudinal data obtained from questionnaires administered to every grade of ward and school staff involved in the training of learners. Using recently developed statistical methods, it was possible to select from the hundreds of criteria studied those which were clearly associated with ‘better’ clinical learning environments.
The findings
The findings from this study are extensive and are linked to three stages in the analysis: (1) Descriptive analyses were produced from each questionnaire, from the evaluation of wards as learning environments, from the ward activity analysis and analyses of staffing levels, patient turnover and bed occupancy. These findings are useful in simply describing the information available from each of our data sources. No attempt is made at this stage to relate data from different sources. (2) Using the evaluation of the wards to identify two groups of wards, those ‘better’ and those ‘worse’ wards in terms of the learning environment, the effect of any other factor vis-a-vis the ‘better’ and ‘worse’ wards was examined. For example, whether the ‘better’ wards had more staff; whether the ‘worse’ wards had higher workloads; whether the impact of clinical teachers was significant in the ‘better’ wards, etc.
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(3) Using a multivariate statistical method, those critical factors which best discriminated between ‘better’ and ‘worse’ wards were identified. It emerged that the critical factors were easily measurable, and thus that future wards could be assessed as ‘better’ or ‘worse’ through a simple measurement of these critical factors. This paper will concentrate on those findings which have direct or indirect manpower implications. These will be separately discussed for each of the above stages of the analysis. The question arises as to whether the findings of this study are widely applicable, i.e. do the findings apply to specialties other than medicine, and do the findings apply outside Northern Ireland where the study was carried out? It can be asserted with some confidence that the findings apply to medical wards in the rest of the U.K. This view is supported by the opinions of nurse administrators and educators, who have pointed out that the syllabus for training is similar and that the educational objectives for learners in Northern Ireland would be similar to those of learners in the rest of the U.K. The findings from this study suggest that the relationships revealed were not peculiar to medical wards. For example, of all the factors which were associated with good nurse education in medical wards, none was speciality specific. It is therefore suggested that the findings may well apply across most specialties used for basic nurse training with some obvious exceptions like psychiatry or community experience. With regard to manpower, all the indications are that Northern Ireland as a whole has higher levels of staffing that the rest of the U.K.*, i.e. more hospital nurses per bed, more registered nurses per 1000 of the population (for example, Merrison (1979), [Table l] . The manpower implications of this study are that effective nurse education can be sustained by the present level of staff in Northern Ireland, given better use of resources-but only just. Any reductions in present levels of staff are likely to be to the detriment of nurse ec acation. Given that staffing levels are already lower in the rest of the U.K., it therefore follows that any further cuts will result in less effective nurse education, and consequently lower standards of care, in the U.K. as a whole. Although Northern Ireland, as a region, is relatively well-staffed, acute manpower problems exist because of the inequitable distribution of services and staff. Medical services and hospitals are very heavily concentrated into Belfast and the east of the Province. As a result, over half of Northern Ireland’s nursing learners have trained in Belfast and the eastern area for many decades. Due both to high wastage rates of trained nurses in Belfast, and to a tendency for nurses from rural backgrounds to return home after their training, there is a shortage of trained nurses in Belfast hospitals. Average length of service of staff nurses in the Belfast area was only 6 months after qualifying (Young, 1982) although this situation has improved slightly since 1982. The advice of well-placed contacts in Belfast and in London is that the situation is very similar in other parts of the U.K., where an imbalance in the distribution of resources leads to manpower problems, especially in the large urban teaching hospitals. It is therefore probable that the following discussion of the manpower implications of the Northern Ireland nurse-training study also applies throughout the U.K. Manpower
Implications
The manpower implications of this study are discussed in three sections linked to stages of the analysis: firstly the implications of the descriptive findings of the study, secondly *With the notable
exception
of the community
sector
which is relatively
understaffed
in Northern
Ireland.
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the implications of the relationship between various factors and effective nurse training and thirdly the implications of the selected criteria which most significantly discriminated between the wards which were most effective for training learners and the wards which were least effective. Implicarions of the descriptive findings Descriptive findings are available from a variety of sources: (i) hospital statistics on staffing levels, bed occupancy and patient turnover; (ii) a dependency study using Barr’s method (1967) on all patients in the study wards over a 13-week period; (iii) an activity analysis geared to an investigation of nursing activity as it relates to the training of learners; (iv) interviews carried out with sisters, staff nurses, learners, clinical teachers and tutors; (v) an investigation of how much experience learners actually gained during a 13-week allocation. The descriptive information provided by these sources has manpower implications of three kinds; hospital/managerial implications, implications for the use of manpower resources on the ward and implications for the schools of nursing. Hospital/managerial manpower implications. Staffing levels remained remarkably constant over the 13-week period of study. On no ward was there any evidence that levels of staff were altered to take account of workload. Workload, on the other hand, did fluctuate very considerably within wards, yet there was no evidence that extra staff were allocated to wards to deal with increased workloads. When available nurse hours per patient were considered, the same conclusion emerged; staffing complements had little to do with the numbers of patients in the ward, or with their nursing needs, as measured by dependency. The findings suggested that the establishment for a ward is fixed at some level, probably determined by the number of beds in the ward (N.B. not the number of occupied beds), and that the fixed staff complement was rarely altered. The findings revealed some anomalous distributions of staff within certain hospitals. For example, in one hospital, the workload per nurse was twice as high on average in one medical ward as it was in the other medical ward, which was identical in structure, patient turnover and bed occupancy. This was because the first ward had many more very ill patients, but the same number of staff as the second ward. There seems, therefore, to be considerable scope for effecting better distribution of trained staff, at least within hospitals. Certain hospitals, however, had particular problems of manpower shortages which directly affected nurse education. The concentration of learners in Belfast hospitals was considerably in excess of that in rural hospitals. The recruitment of learners in those Belfast hospitals had risen alongside shortages of trained staff. There was clear evidence of the use of learner nurses to increase the ‘pairs of hands’ available to a ward. This was reflected by the learners themselves who were very aware that their education and training were taking a low priority on these wards, and that their primary role was as ‘a pair of hands’. This problem also exists in large urban teaching hospitals outside Northern Ireland. There is a cycle of shortages of trained staff, leading to heavy concentrations of learners, leading to lowered standards of education and training for the learner, leading to high wastage rates once the learners have qualified which exacerbates the manpower problem. It is difficult to see how this cycle can be broken unless further trained staff can be recruited. It is therefore a central political argument that the inequitable distributions of resources within the Health
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Service make a nonsense of the usual kinds of manpower statistics quoted. To illustrate this the case of Northern Ireland is appropriate: despite the fact that on most indices quoted Northern Ireland is well served in the nursing sector, this masks the very serious manpower problems of the urban hospitals. It is very hard to see how more efficient use of financial resources can help in an area where there are simply too few trained nurses to meet patients’ needs and trained staff are very difficult to recruit and maintain. Nonetheless, there was evidence that despite the scarce resources in staff, better distribution of these staff would result in more care for those patients who most need it, i.e. some account should be taken of the bed occupancy, patient turnover and dependency of patients in deciding the staffing of wards. There may also be a case for more flexible deployment of staff in response to fluctuating workloads. The counter argument here is that continuity of care could be adversely affected if staff were moved around. The findings suggested, however, that with a 37.5 h working week, and very high levels of staff turnover, continuity of care may, in any case, be a myth. It might be preferable to employ staff in a more flexible way, allocating extra staff, perhaps from a small ‘pool’, to those wards where the patients are most in need of nursing care, at any given time. Ward manpower implications. Findings were produced on the ratios of trained staff to learners on the study wards. These data were averaged over a 3-month period. Of the 25 study wards only five had more trained staff than learners. Few other wards came close to a one-to-one ratio. A number of wards had on average about four learners per trained nurse, the highest concentration of learners observed, and those wards were in the urban hospitals. These ratios are similar to those reported in the rest of the U.K. As evidence Table 1 gives the average of trained staff per learner over a 3-month period from the present Table I. Ratio of trained staff per learner over a 3-month period 25 Wards (N.I.
study)
6 Ward5 (C B. study) __._
0.38
0.67
0.51
0.48
0.45
0.45
0.31
0.67
0.33
0.31
3.32
0 11
0.48 0.46 0.43 0.46 0.54 0.29 1.18 0.28 0.28 0.30 3.51 0.66 0.71 0.49 I42 0.84 0.62 0.58 I.60
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study findings, and, for the purposes of comparison, the results produced by Fretwell (1982)* from her study of six wards in one District of England. Inspection of the table shows that the range of trained/learner ratios was on the whole roughly comparable between the N.I. wards and the G.B. wards. The only difference lies in a small number of N.I. wards which had very favourable trained/learner ratios. This was due to the fact that a training school was not fully operational at the time of the N.I. study and thus only small numbers of learners were being allocated to wards at that time. Otherwise Fretwell reported a range of ratios which was very similar to those found in the N.I. study. It would therefore seem to be the case that, taken as a whole, the range of ratios of trained staff to leavers found in the N.I. study would be broadly similar to the ratios which exist in wards in the rest of the U.K. Furthermore, contact with researchers working on aspects of nurse training in the clinical area in G.B. indicates that most of the present study findings on the ward-learning climate are being closely replicated by their findings. It is therefore suggested that the following discussion of manpower implications would apply throughout the U.K. The survey of ward sisters revealed that sisters on urban wards (i.e. mostly working in the large teaching hospitals) were relatively young and inexperienced. Young (1982) found that half of the sisters working in the Belfast area had been appointed under the age of 23. This phenomenon, which resulted from high staff turnover, meant that the sisters were lacking in postqualification clinical experience and found the responsibilities of the job difficult to handle. Many such sisters reported that they had problems enough in maintaining standards of patient care and dealing with administrative work. The needs of learners were, of necessity, at best a second-order priority. The analysis of ward activity confirmed the sisters’ accounts. Sisters spent only 2% of their time teaching learners. Ward work was not organized to make best use of resources. Learners tended to work alongside their peers, as did trained staff, even when there were enough trained staff to provide good levels of supervision. There was therefore considerable loss of potential in training learners. This was further confirmed by the survey of staff nurses. Again manpower shortages in the urban teaching hospitals had resulted in a high proportion of very young staff nurses without a great deal of clinical experience. These staff nurses, finding difficulty in their own roles, were not particularly aware of the needs of learners and did not perceive nurse training as an important part of their role. It is suggested, therefore, that the manpower problems in the urban hospitals are directly, and detrimentally affecting the quality of nurse education. Manpower implications for nurse educators. Serious problems resulting from manpower shortages, both in the tutor and clinical teacher grade, were revealed by the study. It is believed, through research contacts in G.B., that the situation in the rest of the U.K. is, if anything, worse, For example, the ratio of teachers to learners for England and Wales in 1981-1982 (The General Nursing Council for England and Wales, Annual Report, 1981-82) was 1:22.26. Figures obtained from the Northern Ireland National Board show that the equivalent ratio was 1: 17.56. It is therefore suggested that the following discussion of manpower results from the N.I. study would apply to the rest of the U.K., and that the problems in the rest of the U.K. could indeed be more acute. The central manpower problem is in the tutor grade. Some years ago it was stipulated that nurses should have at least 2 years’ clinical experience, before entering a tutor or *Fretwell produced appropriately/weiqhted
her ratios separately for morning and afternoon average of the ratios for these two periods.
shifts.
The figures
in the table are an
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clinical teacher course. There was a subsequent shortage of both tutors and clinical teachers. A practice then developed in a number of schools of Nursing of using clinical teachers to give lectures in the school of Nursing and in a number of other ways to augment scarce resources in the tutor grade. This has resulted in a critical shortage of clinical teaching on the wards. The findings revealed a strong association between low levels of clinical experience in clinical teachers and the wards which provided the least favourable learning enivironment on evaluation. This point will be expanded in the next section. It is believed, therefore, that the manpower shortages in both the clinical teacher and tutor grade have contributed directly and detrimentally to the education of learners on the wards. Two-thirds of the learners participating in the study never saw a clinical teacher in an entire 13-week ward allocation. Manpower shortages in both the tutor and clinical teaching grades have led to the employment of considerable numbers of nurse teachers who are lacking in clinical experience. The problem is particularly acute in the clinical teacher grade since this is seen as a ‘stepping stone’ to the tutor grade. Average length of service in the clinical teacher grade was less than 1 year in the case of male clinical teachers, and just under 2 years for female clinical teachers. It must also be stressed that the workload on clinical teachers in post was very heavy. The ratio of clinical teachers to students would compare unfavourably with almost any other sector of education. It has been demonstrated that in the three areas previously mentioned manpower problems have been clearly identified on the basis of the descriptive findings. The next stage in the argument is to relate various manpower-related variables to the evaluation of wards as training areas. In the following sections it will be shown that various kinds of manpower shortages are directly associated with lower standards of nurse education in the clinical area.
The relationship between manpower shortages and nurse education on the ward Discussion of manpower is often carried out without reference to the effect of manpower on any specific desired standards of output or performance. This is particularly a problem in the use of manpower-type statistics in nursing. To our knowledge no manpower analysis of nursing has been able to link manpower in an unarguable way with standards of care or standards of nurse education. This study can attempt the latter. Using the evaluation of wards as learning environments it was possible to identify 2 groups of wards which were markedly different in calibre as training areas, one group being considerably better than the other. The two groups of wards were designated as ‘better’ and ‘worse’ wards in terms of nurse training. All of the following discussion hangs on the relationships discovered between variables with manpower implications and the calibre of wards as learning environments. It was found that the ‘worse’ wards were characterized by problems resulting from manpower shortages both of clinical teachers and of trained ward staff. The ‘worse’ wards had both sisters and staff nurses who were relatively young and lacking in clinical experience. The lack of confidence and inexperience of the young ward sisters was illustrated by their attitudes to nurse education which were authoritarian and opposed to a proper emphasis on theory. The young ward sisters were less familiar with the educational objectives of the learners, and were less likely to organize a learner’s time in such a way that the learner benefited educationally. The use of learners as ‘ pairs of hands’ was prevalent in those wards with young inexperienced sisters, and these same wards were evaluated as being in the ‘worse’ category as learning environments.
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The ‘worse’ wards were further characterized by young and clinically inexperienced clinical teachers. It has already been indicated that the workload on clinical teachers was very high but, nonetheless, it was also found that many clinical teachers did not make the best use of their time. In particular the time available to work alongside and teach learners was not equitably distributed among learners or wards. A factor which was strikingly different between the ‘better’ and ‘worse’ wards was the amount of educational contact the learners had with trained staff. Equally striking was the fact that the ratio of trained staff to learners, workload and staff per bed did not differ markedly in the ‘better’ and ‘worse’ wards. This was because the ‘better’ wards made best use of the staff available to increase the educational contact between trained staff and learners. The findings strongly suggest that more effective nurse training could have resulted in every single study ward through better deployment of trained staff. In some of the ‘worse’ wards, however, the level of trained staff was barely sufficient to allow the effective training of the number of learners being allocated, even given optimal utilization of trained staff. In summary then, strong relationships were found between many factors due to manpower shortages and lowered standards of nurse training. It was further found, however, that more efficient use of trained staff could significantly enhance the educational experience of learners on wards. How to determine the numbers of learners who can be effectively supported on a ward. The final stage in the analysis was to use a multivariate statistical technique to select a small number of factors which could, in practice, be used to determine the number of learners who could be effectively supported. It is stressed that this selection is not of those factors which are solely important but of those which can be used as an instrument for determining future allocations of learners. This exercise was carried out separately for each of three stages of learner. It was clear from this analysis that in determining the number of learners who could be effectively supported, a crucial factor was the amount of contact that learners had with trained ward staff. This clearly has manpower implications. From the study, it was possible to estimate the amount of contact that learners needed for effective support to be achieved. This is a crude estimate since factors other than contact need to be considered and the method is designed to be applied on an individual ward basis. The study results nonetheless suggested that 30% of a learners’ time in contact with trained staff was likely to result in effective support. Given that a trained nurse cannot always be in contact with a learnerfor example a sister or indeed a staff nurse must have confidential interactions with both relatives and doctors-it is suggested that a staff nurse could be in contact with learners for at most 60% of her time. This means that a staff nurse could offer effective support to two learners. A sister could in all probability offer support of 30% of her time to at most one learner. It is therefore recommended, as a crude rule of thumb, that the ratio should be at most two learners per trained nurse (2:l). Taking Northern Ireland as a whole the ratio of 2:l is available. This masks, however, the problems already referred to, arising from inequitable distribution of resources. In large urban teaching hospitals a ratio of 4:l is not uncommon. The findings would therefore support the case for a redistribution of learners. This, however, would have further horrendous manpower implications for the nursing service in the urban teaching hospitals. Alternatively an increase in trained staff would be desirable in those areas where learners are concentrated.
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The amount of clinical teaching also emerged as an important determinant of the number of learners who can be effectively supported. On a further crude estimate, it is clear that the present levels of clinical teaching are not sufficient to ensure effective support.
Conclusions
Given that manpower indices in the rest of the U.K. are comparable with Northern Ireland, the findings of this study clearly suggest that nurse education is at risk because of manpower shortages.The difficulty in making a political argument lies in the fact that an assessment of resources at regional level, for example, masks the inequalities within the region-Northern Ireland would have some difficulty in making an argument for extra nursing staff since the Province’s quotas compare favourably with most regions in the rest of the U.K. It therefore seems to be important to challenge the level of the present debate, and to argue that standards of care and standards of nurse education cannot be meaningfully discussed in the context of finance available to a region. This study shows clearly that there is a critical shortage of both tutors and clinical teachers which is directly associated with lower standards of nurse training. This is true across the board-it is a problem for both rural and urban hospitals and the situation in the rest of the U.K. is, if anything, worse than that prevailing in Northern Ireland. With regard to service staff, the study suggests that present manpower in the urban hospitals is not sufficient to ensure adequate supervision for learners. Nonetheless, in the case of Northern Ireland at least, taking the Province’s trained staff as a whole adequate supervision can be provided for the numbers of learners being trained. This depends critically, however, on the effective deployment of resources and there may be implications here for a new emphasis on in-service training. It is fundamentally important, therefore, that the nursing profession makes better use of existing service resources in training learners. This study demonstrates that nurse training can be significantly improved simply by making better use of existing trained staff on the wards. This argument will be pressed by Government. The following two strategies are therefore of importance: (1) Educating ward staff to make better use of existing trained staff. (2) Challenging the present basis of discussion about the Health Services; arguing that at hospital level huge manpower problems exist; arguing that even if the nursing profession makes optimal use of existing staff, manpower problems both in school and service are detrimentally affecting standards of nurse education, and thus future standards of nursing care.
References Reid, N. G. (1983). Nurse Training in fhe Clinical Area. Report to the Northern Ireland Council for Nurses and Midwives Barr, A. (1967). Meusuremenl of Nursing Care. Operational Research Unit Report No.9. Oxford Regional Hospital Board. Fretwell, J. (1982). Wurd Teuching andLeurning. Royal College of Nursing. Merrison, Sir Alec (1979). Royal Commission on the Nutionul He&h Service. London, HMSO, July 1979. Command Paper, CMND 7615. Young, A. (1982). Factors affecting the recruitment and wastage of nurses in Northern Ireland, Report to DHSS, Belfast. (Received 16 July 1984; accepted for publication 17 August 1984)
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Norma Reid is a statistician who has worked in health services research for 10 years. She worked for three years in the Health Care Research Unit, University of Newcastleupon-Tyne, and she was then a lecturer in social statistics at the London School of Economics. Since 1978 she has been engaged in nursing research, and last year set up the Centre for Applied Health Studies in the University of Ulster, the present focus of which is commissioned research in nursing for policy makers and managers. She is a member of the Northern Ireland National Board for Nursing, Midwifery and Health Visiting, and was recently appointed to the Royal College of Nursing Commission on Nursing Education. Her Ph.D. thesis was a statistical investigation of a nursing problem and her recent work on nurse training was described by the Royal College of Nursing as “one of the most significant pieces of nurse research in the last decade”.
1985
t
0020-7489185 $3.00 + 0.00 1985 Pcrgamon Presc Lid
The effective training of nurses: manpower implications NORMAG.
REID, M.Sc., D.Phil., F.S.S. Director, Centre for Applied Health Studies, The University of Ulster, Coleraine BT52 ISA, Northern Ireland.
Abstract--In a period of scarce and shrinking resources, manpower planning is of great importance. One aspect of nurse manpower planning is to ensure that the clinical learning environment is adequate in terms of qualified nursing staff. A recent, detailed study of nurse training in the clinical area has highlighted the effects of manpower shortages in nurse education in the clinical area. It is argued that any further cuts in nurse manpower levels will have a direct, detrimental effect on the clinical learning environment, and this is illustrated by findings from the nurse training study. It is further suggested that the manpower problems of urban hospitals are often masked by discussion of manpower in terms of regional staffing levels.
There are three aspects of manpower planning which are of fundamental importance to the nursing profession: (a) that there are sufficient numbers of nurses in service to maintain acceptable standards of care; (b) that there are sufficient numbers of nurse educators and trained nurse practitioners to ensure an effective training for learner nurses; (c) that sufficient numbers of learners are training to maintain the service, given wastage rates of trained staff. These manpower considerations can lead to incompatible objectives. The nursing service, often under pressure through shortages of trained staff, may well be tempted to increase the ‘pairs of hands’ available to a ward by placing extra learners on the ward. This in turn may well lead to a poor educational experience for the learner because there are not enough trained staff to provide adequate supervision. The effective training of learners is a longterm investment in good standards of patient care, but this cannot be achieved at the expense of patient care in the present. 89
90
NORMA
G. REID
If it is assumed that the present numbers of nurses, both trained and untrained, can deliver acceptable standards of patient care, two questions then arise: (i) Does the ratio of trained ward staff to learners ensure adequate supervision and training for the learners? (ii) Are we training enough nurses to ensure that sufficient numbers of nurses are maintained to deliver acceptable standards of care? Are we replacing nurses lost to the profession through wastage or retirement? A major research study, commissioned in 1979 by the Northern Ireland Council for Nurses and Midwives, and completed in 1983, addressed itself to question (i) above. This paper describes the main findings of that study and discusses the manpower implications of the findings. The method
The terms of reference of this study were ‘to examine the factors which determine the numbers of learners that a clinical area can effectively support’. The study was carried out over a four year period by a multi-disciplinary research team based in the Centre for Applied Health Studies, University of Ulster. Twenty-five wards, used for general medical experience for student nurses, were included in the study. The focus of the study was a 13-week allocation. A detailed evaluation of each ward as a learning environment was carried out. Wards were evaluated in terms of the quantity of relevant experience learners acquired, and in terms of the quality of that experience as reflected in the clinical performance of the learners. This evaluation revealed that there were two distinct groups of wards within the 25 studied, one group consisting of wards which were significantly better as learning environments than the other group. The criteria which distinguished between these two groups were then examined. For example, were the ‘better’ wards better staffed? Hundreds of different criteria were investigated including many aspects of ward activity which was identified through direct observation of ward work by the research team, indices like bed occupancy, staffing levels and patient turnover, organizational factors like the number of consultant rounds and a vast amount of attitudinal data obtained from questionnaires administered to every grade of ward and school staff involved in the training of learners. Using recently developed statistical methods, it was possible to select from the hundreds of criteria studied those which were clearly associated with ‘better’ clinical learning environments.
The findings
The findings from this study are extensive and are linked to three stages in the analysis: (1) Descriptive analyses were produced from each questionnaire, from the evaluation of wards as learning environments, from the ward activity analysis and analyses of staffing levels, patient turnover and bed occupancy. These findings are useful in simply describing the information available from each of our data sources. No attempt is made at this stage to relate data from different sources. (2) Using the evaluation of the wards to identify two groups of wards, those ‘better’ and those ‘worse’ wards in terms of the learning environment, the effect of any other factor vis-a-vis the ‘better’ and ‘worse’ wards was examined. For example, whether the ‘better’ wards had more staff; whether the ‘worse’ wards had higher workloads; whether the impact of clinical teachers was significant in the ‘better’ wards, etc.
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(3) Using a multivariate statistical method, those critical factors which best discriminated between ‘better’ and ‘worse’ wards were identified. It emerged that the critical factors were easily measurable, and thus that future wards could be assessed as ‘better’ or ‘worse’ through a simple measurement of these critical factors. This paper will concentrate on those findings which have direct or indirect manpower implications. These will be separately discussed for each of the above stages of the analysis. The question arises as to whether the findings of this study are widely applicable, i.e. do the findings apply to specialties other than medicine, and do the findings apply outside Northern Ireland where the study was carried out? It can be asserted with some confidence that the findings apply to medical wards in the rest of the U.K. This view is supported by the opinions of nurse administrators and educators, who have pointed out that the syllabus for training is similar and that the educational objectives for learners in Northern Ireland would be similar to those of learners in the rest of the U.K. The findings from this study suggest that the relationships revealed were not peculiar to medical wards. For example, of all the factors which were associated with good nurse education in medical wards, none was speciality specific. It is therefore suggested that the findings may well apply across most specialties used for basic nurse training with some obvious exceptions like psychiatry or community experience. With regard to manpower, all the indications are that Northern Ireland as a whole has higher levels of staffing that the rest of the U.K.*, i.e. more hospital nurses per bed, more registered nurses per 1000 of the population (for example, Merrison (1979), [Table l] . The manpower implications of this study are that effective nurse education can be sustained by the present level of staff in Northern Ireland, given better use of resources-but only just. Any reductions in present levels of staff are likely to be to the detriment of nurse ec acation. Given that staffing levels are already lower in the rest of the U.K., it therefore follows that any further cuts will result in less effective nurse education, and consequently lower standards of care, in the U.K. as a whole. Although Northern Ireland, as a region, is relatively well-staffed, acute manpower problems exist because of the inequitable distribution of services and staff. Medical services and hospitals are very heavily concentrated into Belfast and the east of the Province. As a result, over half of Northern Ireland’s nursing learners have trained in Belfast and the eastern area for many decades. Due both to high wastage rates of trained nurses in Belfast, and to a tendency for nurses from rural backgrounds to return home after their training, there is a shortage of trained nurses in Belfast hospitals. Average length of service of staff nurses in the Belfast area was only 6 months after qualifying (Young, 1982) although this situation has improved slightly since 1982. The advice of well-placed contacts in Belfast and in London is that the situation is very similar in other parts of the U.K., where an imbalance in the distribution of resources leads to manpower problems, especially in the large urban teaching hospitals. It is therefore probable that the following discussion of the manpower implications of the Northern Ireland nurse-training study also applies throughout the U.K. Manpower
Implications
The manpower implications of this study are discussed in three sections linked to stages of the analysis: firstly the implications of the descriptive findings of the study, secondly *With the notable
exception
of the community
sector
which is relatively
understaffed
in Northern
Ireland.
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the implications of the relationship between various factors and effective nurse training and thirdly the implications of the selected criteria which most significantly discriminated between the wards which were most effective for training learners and the wards which were least effective. Implicarions of the descriptive findings Descriptive findings are available from a variety of sources: (i) hospital statistics on staffing levels, bed occupancy and patient turnover; (ii) a dependency study using Barr’s method (1967) on all patients in the study wards over a 13-week period; (iii) an activity analysis geared to an investigation of nursing activity as it relates to the training of learners; (iv) interviews carried out with sisters, staff nurses, learners, clinical teachers and tutors; (v) an investigation of how much experience learners actually gained during a 13-week allocation. The descriptive information provided by these sources has manpower implications of three kinds; hospital/managerial implications, implications for the use of manpower resources on the ward and implications for the schools of nursing. Hospital/managerial manpower implications. Staffing levels remained remarkably constant over the 13-week period of study. On no ward was there any evidence that levels of staff were altered to take account of workload. Workload, on the other hand, did fluctuate very considerably within wards, yet there was no evidence that extra staff were allocated to wards to deal with increased workloads. When available nurse hours per patient were considered, the same conclusion emerged; staffing complements had little to do with the numbers of patients in the ward, or with their nursing needs, as measured by dependency. The findings suggested that the establishment for a ward is fixed at some level, probably determined by the number of beds in the ward (N.B. not the number of occupied beds), and that the fixed staff complement was rarely altered. The findings revealed some anomalous distributions of staff within certain hospitals. For example, in one hospital, the workload per nurse was twice as high on average in one medical ward as it was in the other medical ward, which was identical in structure, patient turnover and bed occupancy. This was because the first ward had many more very ill patients, but the same number of staff as the second ward. There seems, therefore, to be considerable scope for effecting better distribution of trained staff, at least within hospitals. Certain hospitals, however, had particular problems of manpower shortages which directly affected nurse education. The concentration of learners in Belfast hospitals was considerably in excess of that in rural hospitals. The recruitment of learners in those Belfast hospitals had risen alongside shortages of trained staff. There was clear evidence of the use of learner nurses to increase the ‘pairs of hands’ available to a ward. This was reflected by the learners themselves who were very aware that their education and training were taking a low priority on these wards, and that their primary role was as ‘a pair of hands’. This problem also exists in large urban teaching hospitals outside Northern Ireland. There is a cycle of shortages of trained staff, leading to heavy concentrations of learners, leading to lowered standards of education and training for the learner, leading to high wastage rates once the learners have qualified which exacerbates the manpower problem. It is difficult to see how this cycle can be broken unless further trained staff can be recruited. It is therefore a central political argument that the inequitable distributions of resources within the Health
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Service make a nonsense of the usual kinds of manpower statistics quoted. To illustrate this the case of Northern Ireland is appropriate: despite the fact that on most indices quoted Northern Ireland is well served in the nursing sector, this masks the very serious manpower problems of the urban hospitals. It is very hard to see how more efficient use of financial resources can help in an area where there are simply too few trained nurses to meet patients’ needs and trained staff are very difficult to recruit and maintain. Nonetheless, there was evidence that despite the scarce resources in staff, better distribution of these staff would result in more care for those patients who most need it, i.e. some account should be taken of the bed occupancy, patient turnover and dependency of patients in deciding the staffing of wards. There may also be a case for more flexible deployment of staff in response to fluctuating workloads. The counter argument here is that continuity of care could be adversely affected if staff were moved around. The findings suggested, however, that with a 37.5 h working week, and very high levels of staff turnover, continuity of care may, in any case, be a myth. It might be preferable to employ staff in a more flexible way, allocating extra staff, perhaps from a small ‘pool’, to those wards where the patients are most in need of nursing care, at any given time. Ward manpower implications. Findings were produced on the ratios of trained staff to learners on the study wards. These data were averaged over a 3-month period. Of the 25 study wards only five had more trained staff than learners. Few other wards came close to a one-to-one ratio. A number of wards had on average about four learners per trained nurse, the highest concentration of learners observed, and those wards were in the urban hospitals. These ratios are similar to those reported in the rest of the U.K. As evidence Table 1 gives the average of trained staff per learner over a 3-month period from the present Table I. Ratio of trained staff per learner over a 3-month period 25 Wards (N.I.
study)
6 Ward5 (C B. study) __._
0.38
0.67
0.51
0.48
0.45
0.45
0.31
0.67
0.33
0.31
3.32
0 11
0.48 0.46 0.43 0.46 0.54 0.29 1.18 0.28 0.28 0.30 3.51 0.66 0.71 0.49 I42 0.84 0.62 0.58 I.60
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study findings, and, for the purposes of comparison, the results produced by Fretwell (1982)* from her study of six wards in one District of England. Inspection of the table shows that the range of trained/learner ratios was on the whole roughly comparable between the N.I. wards and the G.B. wards. The only difference lies in a small number of N.I. wards which had very favourable trained/learner ratios. This was due to the fact that a training school was not fully operational at the time of the N.I. study and thus only small numbers of learners were being allocated to wards at that time. Otherwise Fretwell reported a range of ratios which was very similar to those found in the N.I. study. It would therefore seem to be the case that, taken as a whole, the range of ratios of trained staff to leavers found in the N.I. study would be broadly similar to the ratios which exist in wards in the rest of the U.K. Furthermore, contact with researchers working on aspects of nurse training in the clinical area in G.B. indicates that most of the present study findings on the ward-learning climate are being closely replicated by their findings. It is therefore suggested that the following discussion of manpower implications would apply throughout the U.K. The survey of ward sisters revealed that sisters on urban wards (i.e. mostly working in the large teaching hospitals) were relatively young and inexperienced. Young (1982) found that half of the sisters working in the Belfast area had been appointed under the age of 23. This phenomenon, which resulted from high staff turnover, meant that the sisters were lacking in postqualification clinical experience and found the responsibilities of the job difficult to handle. Many such sisters reported that they had problems enough in maintaining standards of patient care and dealing with administrative work. The needs of learners were, of necessity, at best a second-order priority. The analysis of ward activity confirmed the sisters’ accounts. Sisters spent only 2% of their time teaching learners. Ward work was not organized to make best use of resources. Learners tended to work alongside their peers, as did trained staff, even when there were enough trained staff to provide good levels of supervision. There was therefore considerable loss of potential in training learners. This was further confirmed by the survey of staff nurses. Again manpower shortages in the urban teaching hospitals had resulted in a high proportion of very young staff nurses without a great deal of clinical experience. These staff nurses, finding difficulty in their own roles, were not particularly aware of the needs of learners and did not perceive nurse training as an important part of their role. It is suggested, therefore, that the manpower problems in the urban hospitals are directly, and detrimentally affecting the quality of nurse education. Manpower implications for nurse educators. Serious problems resulting from manpower shortages, both in the tutor and clinical teacher grade, were revealed by the study. It is believed, through research contacts in G.B., that the situation in the rest of the U.K. is, if anything, worse, For example, the ratio of teachers to learners for England and Wales in 1981-1982 (The General Nursing Council for England and Wales, Annual Report, 1981-82) was 1:22.26. Figures obtained from the Northern Ireland National Board show that the equivalent ratio was 1: 17.56. It is therefore suggested that the following discussion of manpower results from the N.I. study would apply to the rest of the U.K., and that the problems in the rest of the U.K. could indeed be more acute. The central manpower problem is in the tutor grade. Some years ago it was stipulated that nurses should have at least 2 years’ clinical experience, before entering a tutor or *Fretwell produced appropriately/weiqhted
her ratios separately for morning and afternoon average of the ratios for these two periods.
shifts.
The figures
in the table are an
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clinical teacher course. There was a subsequent shortage of both tutors and clinical teachers. A practice then developed in a number of schools of Nursing of using clinical teachers to give lectures in the school of Nursing and in a number of other ways to augment scarce resources in the tutor grade. This has resulted in a critical shortage of clinical teaching on the wards. The findings revealed a strong association between low levels of clinical experience in clinical teachers and the wards which provided the least favourable learning enivironment on evaluation. This point will be expanded in the next section. It is believed, therefore, that the manpower shortages in both the clinical teacher and tutor grade have contributed directly and detrimentally to the education of learners on the wards. Two-thirds of the learners participating in the study never saw a clinical teacher in an entire 13-week ward allocation. Manpower shortages in both the tutor and clinical teaching grades have led to the employment of considerable numbers of nurse teachers who are lacking in clinical experience. The problem is particularly acute in the clinical teacher grade since this is seen as a ‘stepping stone’ to the tutor grade. Average length of service in the clinical teacher grade was less than 1 year in the case of male clinical teachers, and just under 2 years for female clinical teachers. It must also be stressed that the workload on clinical teachers in post was very heavy. The ratio of clinical teachers to students would compare unfavourably with almost any other sector of education. It has been demonstrated that in the three areas previously mentioned manpower problems have been clearly identified on the basis of the descriptive findings. The next stage in the argument is to relate various manpower-related variables to the evaluation of wards as training areas. In the following sections it will be shown that various kinds of manpower shortages are directly associated with lower standards of nurse education in the clinical area.
The relationship between manpower shortages and nurse education on the ward Discussion of manpower is often carried out without reference to the effect of manpower on any specific desired standards of output or performance. This is particularly a problem in the use of manpower-type statistics in nursing. To our knowledge no manpower analysis of nursing has been able to link manpower in an unarguable way with standards of care or standards of nurse education. This study can attempt the latter. Using the evaluation of wards as learning environments it was possible to identify 2 groups of wards which were markedly different in calibre as training areas, one group being considerably better than the other. The two groups of wards were designated as ‘better’ and ‘worse’ wards in terms of nurse training. All of the following discussion hangs on the relationships discovered between variables with manpower implications and the calibre of wards as learning environments. It was found that the ‘worse’ wards were characterized by problems resulting from manpower shortages both of clinical teachers and of trained ward staff. The ‘worse’ wards had both sisters and staff nurses who were relatively young and lacking in clinical experience. The lack of confidence and inexperience of the young ward sisters was illustrated by their attitudes to nurse education which were authoritarian and opposed to a proper emphasis on theory. The young ward sisters were less familiar with the educational objectives of the learners, and were less likely to organize a learner’s time in such a way that the learner benefited educationally. The use of learners as ‘ pairs of hands’ was prevalent in those wards with young inexperienced sisters, and these same wards were evaluated as being in the ‘worse’ category as learning environments.
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The ‘worse’ wards were further characterized by young and clinically inexperienced clinical teachers. It has already been indicated that the workload on clinical teachers was very high but, nonetheless, it was also found that many clinical teachers did not make the best use of their time. In particular the time available to work alongside and teach learners was not equitably distributed among learners or wards. A factor which was strikingly different between the ‘better’ and ‘worse’ wards was the amount of educational contact the learners had with trained staff. Equally striking was the fact that the ratio of trained staff to learners, workload and staff per bed did not differ markedly in the ‘better’ and ‘worse’ wards. This was because the ‘better’ wards made best use of the staff available to increase the educational contact between trained staff and learners. The findings strongly suggest that more effective nurse training could have resulted in every single study ward through better deployment of trained staff. In some of the ‘worse’ wards, however, the level of trained staff was barely sufficient to allow the effective training of the number of learners being allocated, even given optimal utilization of trained staff. In summary then, strong relationships were found between many factors due to manpower shortages and lowered standards of nurse training. It was further found, however, that more efficient use of trained staff could significantly enhance the educational experience of learners on wards. How to determine the numbers of learners who can be effectively supported on a ward. The final stage in the analysis was to use a multivariate statistical technique to select a small number of factors which could, in practice, be used to determine the number of learners who could be effectively supported. It is stressed that this selection is not of those factors which are solely important but of those which can be used as an instrument for determining future allocations of learners. This exercise was carried out separately for each of three stages of learner. It was clear from this analysis that in determining the number of learners who could be effectively supported, a crucial factor was the amount of contact that learners had with trained ward staff. This clearly has manpower implications. From the study, it was possible to estimate the amount of contact that learners needed for effective support to be achieved. This is a crude estimate since factors other than contact need to be considered and the method is designed to be applied on an individual ward basis. The study results nonetheless suggested that 30% of a learners’ time in contact with trained staff was likely to result in effective support. Given that a trained nurse cannot always be in contact with a learnerfor example a sister or indeed a staff nurse must have confidential interactions with both relatives and doctors-it is suggested that a staff nurse could be in contact with learners for at most 60% of her time. This means that a staff nurse could offer effective support to two learners. A sister could in all probability offer support of 30% of her time to at most one learner. It is therefore recommended, as a crude rule of thumb, that the ratio should be at most two learners per trained nurse (2:l). Taking Northern Ireland as a whole the ratio of 2:l is available. This masks, however, the problems already referred to, arising from inequitable distribution of resources. In large urban teaching hospitals a ratio of 4:l is not uncommon. The findings would therefore support the case for a redistribution of learners. This, however, would have further horrendous manpower implications for the nursing service in the urban teaching hospitals. Alternatively an increase in trained staff would be desirable in those areas where learners are concentrated.
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The amount of clinical teaching also emerged as an important determinant of the number of learners who can be effectively supported. On a further crude estimate, it is clear that the present levels of clinical teaching are not sufficient to ensure effective support.
Conclusions
Given that manpower indices in the rest of the U.K. are comparable with Northern Ireland, the findings of this study clearly suggest that nurse education is at risk because of manpower shortages.The difficulty in making a political argument lies in the fact that an assessment of resources at regional level, for example, masks the inequalities within the region-Northern Ireland would have some difficulty in making an argument for extra nursing staff since the Province’s quotas compare favourably with most regions in the rest of the U.K. It therefore seems to be important to challenge the level of the present debate, and to argue that standards of care and standards of nurse education cannot be meaningfully discussed in the context of finance available to a region. This study shows clearly that there is a critical shortage of both tutors and clinical teachers which is directly associated with lower standards of nurse training. This is true across the board-it is a problem for both rural and urban hospitals and the situation in the rest of the U.K. is, if anything, worse than that prevailing in Northern Ireland. With regard to service staff, the study suggests that present manpower in the urban hospitals is not sufficient to ensure adequate supervision for learners. Nonetheless, in the case of Northern Ireland at least, taking the Province’s trained staff as a whole adequate supervision can be provided for the numbers of learners being trained. This depends critically, however, on the effective deployment of resources and there may be implications here for a new emphasis on in-service training. It is fundamentally important, therefore, that the nursing profession makes better use of existing service resources in training learners. This study demonstrates that nurse training can be significantly improved simply by making better use of existing trained staff on the wards. This argument will be pressed by Government. The following two strategies are therefore of importance: (1) Educating ward staff to make better use of existing trained staff. (2) Challenging the present basis of discussion about the Health Services; arguing that at hospital level huge manpower problems exist; arguing that even if the nursing profession makes optimal use of existing staff, manpower problems both in school and service are detrimentally affecting standards of nurse education, and thus future standards of nursing care.
References Reid, N. G. (1983). Nurse Training in fhe Clinical Area. Report to the Northern Ireland Council for Nurses and Midwives Barr, A. (1967). Meusuremenl of Nursing Care. Operational Research Unit Report No.9. Oxford Regional Hospital Board. Fretwell, J. (1982). Wurd Teuching andLeurning. Royal College of Nursing. Merrison, Sir Alec (1979). Royal Commission on the Nutionul He&h Service. London, HMSO, July 1979. Command Paper, CMND 7615. Young, A. (1982). Factors affecting the recruitment and wastage of nurses in Northern Ireland, Report to DHSS, Belfast. (Received 16 July 1984; accepted for publication 17 August 1984)
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Norma Reid is a statistician who has worked in health services research for 10 years. She worked for three years in the Health Care Research Unit, University of Newcastleupon-Tyne, and she was then a lecturer in social statistics at the London School of Economics. Since 1978 she has been engaged in nursing research, and last year set up the Centre for Applied Health Studies in the University of Ulster, the present focus of which is commissioned research in nursing for policy makers and managers. She is a member of the Northern Ireland National Board for Nursing, Midwifery and Health Visiting, and was recently appointed to the Royal College of Nursing Commission on Nursing Education. Her Ph.D. thesis was a statistical investigation of a nursing problem and her recent work on nurse training was described by the Royal College of Nursing as “one of the most significant pieces of nurse research in the last decade”.