Lack of nurses: a serious social problem

Alba Brugués
 

The nursing shortage is a well-known problem throughout the world and has been exacerbated by the effect of the pandemic. According to a WHO report published in 2020, there are 28 million nurses in the world, constituting 59% of health professionals. Currently, the shortage of nurses is estimated at 5.9 million. The report highlights that if action is not taken, by 2030 there will be a shortage of 10.6 million nurses worldwide. In Spain, it is estimated that there are 120,000 missing and in Catalonia 24,000.

Caring for complex patients in the community requires a radical change

Jordi Varela

Editor

The pandemic has highlighted the need to protect, even more, if possible, people suffering from clinical complexities and some of them, in addition, family, economic or social difficulties. For this reason, some primary care centres have set up nursing teams to more proactively care for the most vulnerable patients. These groups of nurses have taken the initiative and now organize their tasks, most of them at home, in an autonomous way, according to a fine balance between coordination and effectiveness. The historical medical-nurse binomial of primary care, then, is beginning to show cracks that give way to advanced organizational models with more nursing skills.

Mental health: involuntary treatment and its consequences

Andrés Fontalba

"If Mr. McMurphy doesn’t want to take his oral medication [...], I'm sure we can administer it in another way."

The character of nurse Mildred Ratched in One Flew Over the Cuckoo's Nest presents a serious, strict, orderly and authoritative figure, with a lot of self confidence and all her actions are carried out with the firm conviction that they are aimed at the welfare of the patients in her care. If we asked her if she takes into account the patients' point of view she would answer, without a doubt, affirmatively. The clear example appears in a discussion in which she is asked to watch a game of baseball on television where she goes the extra mile in persuading all that everyone's vote is necessary for any change in the usual programming, thus she finally manage to impose her point of view. She would not hesitate at any time to use persuasion, interpersonal influence, or even threat to guarantee the administration of a prescribed treatment.

Child care: a nursing perspective

Alba Brugués

Do all professionals working in primary care develop their professional skills adequately? My answer is no, and I believe that the paediatric service of primary care is one of the services in which there is more room to rethink the model of care. To make it easier, I will explain the model of childhood health (this is how I like to express it) that we have been developing for some years at the Can Bou Health Center (CASAP). A model that is gradually becoming known and extended to other primary care centres and which has been presented to national and European congresses and has received great interest on the part of managers and experts in paediatrics and who, at the moment, is offering specific training for those who want to a change orientation of the care of children and their families in primary care.

Self-management: Buurtzorg Identity

Frederic Laloux in "Reinventing organizations" describes the teal-evolutionary companies as those based on the personal growth of their employees and chooses Buurtzorg Netherland as an organization to which we should be paying attention to if we are among those who believe that the time to do things differently has arrived.

What is Buurtzorg Netherland?

Buurtzorg Netherland is a non-profit company, which was founded in 2007 in the Netherlands, when a group of community nurses rethought their work and came to believe that, instead of only going to homes and exercising the functions of their profession, they should advance to becoming the patients’ referee and take charge of attending to their global needs.

Buurtzorg, a nurse work project with blue ocean strategy

10 years ago, the home care scenario for people with complex social and health needs in the Netherlands followed a bureaucratic scheme based on nursing work on one hand, social work on the other, in addition to the home support actions offered by companies, many of them from the cleaning service world. Jos de Blok, a community nurse, dissatisfied with this fragmented model, put an entrepreneur hat on, assembled a small group of nurses with whom he shared vision and discussed as much at large about a new model of care based on real needs of people. In an interview, Jos de Blok says, "What I wanted to show was that if you are a good nurse, you should know how to focus on the relationship and to build trust with patients in order to make them live with the maximum of independence possible. "

Hospitals: 10 necessary structural reforms

Hospitals are structures that generate a powerful influence on the overall health system. Their effectiveness in the resolution of certain acute diseases, especially surgical, gives them a great social prestige. This fact should not, however, hide two structural problems that are burdening their perspective:

a) The first problem is internal. Bureaucracies themselves are showing signs of fatigue and this affects the quality of services, especially in the safety of admitted patients.

Saving Plans: 5 Errors and 5 Proposals

Remember the games of the analogue times, precisely the moment when the player put the piece in the wrong place and there came a warning sound and the red light lit up the nose? Now it looks like a naff old thing, but I liked that Robert Kaplan and Derek Haas have chosen the image of one of these games, precisely one that is for operating a patient and that they have chosen it to illustrate their article published in the Harvard Business Review blog, "How not to cut health care costs".

When faced with budget cuts, they say, health managers around the world apply the same recipe: reducing staff costs (both in numbers and in wages), optimize the use of space to save general services, stop investments and rationalize spending. The authors do not maintain that this package of measures is poorly done, but they question whether behind these policies there isn’t a strategic way of thinking that combines resources to achieve the best results in the most efficient manner possible and the efforts of the basic savings pack can become counterproductive for the health of people and also for the economy of organizations.

Therefore, we should appreciate that the article analyzes five errors of the basic savings pack, while proposing five alternatives focused on efficiency and effectiveness.

Advanced practice nurses: it’s time to strongly support

According to International Council of Nurses, an advanced nursing practitioner is a specialist who has acquired the expert knowledge, the capabilities of making complex decisions and the necessary clinical competencies for expanded practice.

The concept emerged in the US, in the 70s, in the areas of obstetrics and anaesthesia and, thereafter, the development of the nursing profession has focused on what has been renamed Advanced Nursing Practice (ANP). It’s a graduate training that provides an overview for the care of complex patients, for the involvement of people in managing their own diseases and, in short, for everything that regards innovation, evidence and research aimed at improving the care offered to people.

Hospitals and frail elderly patients

Health Service Journal published a report from a committee of experts based on several previous publications, including the British Geriatric Society, Future Hospital Report and King's Fund. From the conclusions of the report I want to highlight some ideas that in my opinion are important:

a) Age should never be a barrier to receiving appropriate, coordinated, safe, efficient and effective care.

b) Integration of social and health services within the community framework is the best approach that can be offered to the group of frail elderly people, although this does not prevent the occurrence of circumstances that may require hospitalization.

c) The emergency departments of hospitals should have the geriatric culture well established in order to make appropriate choices and avoid unnecessary admissions.

d) If the frail person qualifies for hospitalization, the practice of geriatric assessment is imperative as is the practice of developing an individualized treatment plan, because it has been shown that if this methodology is followed through, patients are 30% more likely to survive and go home.

Hospital wards (1): nurses and clinical safety

Often, when we talk about clinical safety, we refer to specific activities such as hand washing or surgical checklist, but in this post I will try to explain the repercussions that the methods of working in hospital wards have on the quality of care. When people are admitted to a hospital, they put themselves in the hands of an army of professionals, who follow guidelines and are subject to shifts and medical guards. We must pay attention to all this, because the evidence has been warning us that what we call organizational factors weigh more than we think when it comes to hospitalized people’s health.

The 12-hour shifts are less secure for patients than the 8 hours shifts

A study conducted by the University of Maryland concludes that the probability of error is 3 times higher for nurses who work in 12-hour shifts compared to the one who work on 8 hours shifts. This finding has been corroborated by extensive research (22,000 records) conducted by the School of Nursing at the University of Pennsylvania.

Nurses: (+) training (-) workloads = (-) mortality

A few months ago, Mireia Subirana, Director of Care at "Consorci Hospitalari de Vic" explained in a post the results of her doctoral thesis that can be summarized as: "more nurses and more training (in hospital wards) was associated with better clinical outcomes". Following this thread, The Lancet has just published the results of a retrospective observational study that has explored whether the nurses training levels and workload ratios could influence the mortality of patients admitted for medium complexity scheduled surgery.

It’s an important work undertaken in 300 hospitals in 9 European countries by surveying 26.516 nurses and analysing 422.730 hospitalization surgical episodes. Despite the expected methodological difficulties of a project of this nature, it can be considered as a rigorous study.

Hospitals: 10 necessary structurals reforms

Hospitals are structures with a powerful influence on the overall health system. Its effectiveness in solving certain acute health problems, especially in the surgical area, gives them a major social prestige. However this fact should not undermine two structural problems that are weighing their image down:

a) The first problem is internal. The own bureaucracies are showing signs of fatigue and this affects the service quality, especially when it comes to the safety of admitted patients.

b) The second problem is relational. The hierarchical superiority of hospitals has placed them apart from the communitarian reality and the primary care, and causes now a serious difficulty in dealing, in an integrated manner, with the complex chronic disease care and with the geriatric frailty.

Nurse demand management in primary care

Nurse demand management, aims to respond, within the scope of the nursing profession, to people who go to a primary care centre with a health problem that requires special attention. This clinical activity must be differentiated from the nurse triage in the emergency services, which offers: reception, attendance and classification of the problem, without any  further clinical activity.

In 2005, the Primary Care Center Can Bou in Castelldefels, near Barcelona, launched a pioneering experience in nurse demand management and subsequently prepared a "Guide to nursing interventions" with the following groups’ classification:

1. The health problems where the formalization allows the nurses to be the ones who finalize the clinical process and therefore they themselves are responsible for the reception of patients and resolution of health problems.
2. Problems of possible emergency intervention in which nurses are autonomous only in the first part of the algorithm. After, there’s a protocol point where the doctor intervenes.
3. Health problems requiring an initial assessment of severity by the nurse prior to the doctor’s intervention.

Impact of nurse staffing on clinical outcomes

In preparing this post, I invited Mireia Subirana, nurse and Director of Care Department at Hospital de  Vic (Catalonia), to present the contents of her doctoral thesis. It’s not a common occurrence for any nurse to get a doctor degree (University of Leeds). She now has a PhD degree and is a Fellow of the European Academy of Nursing Science.

But Subirana has not only been invited to praise her professional and academic career, but because I think it's worth explaining at exactly what point her research is at, having raised a hypothesis that affirms that if nurses from the hospital wards are well educated and the plans are well sized, this may have an impact on clinical outcomes of hospitalised patients. 

In the last ten years, research has established and endorsed the relationship between nurse staffing characteristics and clinical outcomes of hospitalised patients and thus objectifies the contribution of nurses in the care process. It remains to be found how this relationship is established, and the mechanisms that articulate it. This work, with a realistic methodological approach, identifies key factors in the process of care (monitoring, clinical trial, the level of training, experience and the tasks that they have not been able to do) along with the characteristics that define magnetic hospitals are articulated as possible mechanisms that could explain the impact of nurse staffing on patient outcomes.

Readmissions (2). What are the experiences that are yielding results?

The Congress Investigation Services of the US (CRS) published in September 2010, in support of the Obamacare, a report on charges for Medicare of hospital readmissions. The very well documented report assumes that 17.6% of discharge bills issued by hospitals to Medicare are due to the readmissions occurred within 30 days of discharge. Therefore, the two economists who signed the report assumed that they found in the readmissions a source for collecting Medicare savings, moreover taking into account that the variations between areas were making it possible to foresee that an adjustment in the contracting model could be fruitful.

From this document I liked the classification of the actions aimed at reducing readmissions, actions that as it will be seen to be effective, must be tailored to the complexity of the elected patients.

Model 1: very complex patient, intensive action

Heart failure: what works?

Heart failure is the end result of most heart diseases, especially ischemic coronary disease. This is a highly prevalent chronic condition among older people (6-10% in those over 65 years), which provides a great disease burden to the healthcare system.

Both for its origin, which is none other than the long-term failure of acute cardiac pathology, as well as for its diagnosis, the cardiologists, and not the family physicians are the ones leading the management of some clinical processes that are almost always torpid and uncertain and which require a lot of action in the community and a lot of coordination between the hospital and primary care; as you can see, it’s not an easy business.

Heart failure, unlike diabetes, is a chronic process that, as I have already mentioned, slips away from the hands of the family doctor. To begin with at the time of diagnosing, because the clinical diagnosis is only presumptive and sending the patient to the hospital for an echocardiogram confirmation is required. It now appears, however, that it has been shown that the "NT-proBNP*" test (Verdú 2012), detectable in both blood and urine testing is sufficiently cost-effective to be able to expect that primary care units could begin to autonomously solve the diagnosis.

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(*NT-proBNP. Natriuretic peptides are hormones with diuretic and vasodilator effects, segregated mainly in the left ventricle as a compensatory mechanism for a pressure overload).