Two weeks ago I went to Madrid for the mid-point evaluation of the Registered Nurse Forecasting (RN4CAST) project. I’ve been involved in research on the contribution of the nursing workforce to hospital performance for some years, working with Linda Aiken at the University of Pennsylvania in the International Hospitals Outcome Study. In the English arm of the study we showed that hospitals with the best patient-to-nurse ratios had consistently better outcomes than those in hospitals with less favourable staffing, with substantially lower mortality, while the nurses in those hospitals were about twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care on their wards and hospitals. RN4CAST is now expanding this work to 11 European countries (Belgium, Finland, Germany, Greece, Ireland, Poland, Spain, Sweden, Switzerland, The Netherlands, and the UK), the USA and three International Cooperating Partner Countries of the European Union (Botswana, China, and South Africa) plus one reference group (Norway). I’ve been asked to be one of the evaluators of the project and I was delighted to see the tremendous progress so far. This study will provide invaluable insights that go beyond its original aims, to shed light on the processes and quality of care in European hospitals.


I was also asked to give a plenary lecture at the conference that was linked to the meeting. The project places a high priority on engagement with policy makers and had brought together a large number of key stakeholders from Spain and the rest of Europe. I focussed my talk on the challenges facing the nursing profession in the future.

The first set of challenges arise from the changing nature of health care. These include changing demographics, disease patterns, and professional roles. This has profound implications for the general nurse who faces:

• Loss of much of traditional caring role (to health care assistants)

• Increase in the need for clinical knowledge (of drugs, interactions, side effects)

• Increase in the need for technical skills (new equipment for patient monitoring and treatment, information technology)

• Increase in the treatment co-ordination role (among many more actors, and with a much more mobile group of patients)

• Increase in need for vigilance to identify patients deviating from the expected clinical trajectory

• Increase in working in different settings, often involving greater autonomy

Unfortunately, health systems do not always rise to these challenges, exemplified by a paper in J Health Serv Res & Pol in which a researcher described their stay in a hospital: ““Care was being delivered by a group of professional and semi-professional workers, each of whom occupied their own silo, occasionally picking up information from others to initiate some action, or acting in ways that triggered actions by others, but who were unable to see how they formed part of a whole system”

A second challenge is the recruitment and retention of nurses, with many industrialised countries far too dependent on recruitment of nurses from developing countries that can ill afford to lose them.

The third challenge is how to get the balance right between curing and caring. Too often we focus on the technical aspects of care, encouraged by the focus in some countries on what can be measured, while ignoring the human aspects.

Fourth is the need to strengthen professionalism. In some countries professionalism needs to be developed, where nurses are still viewed as doctors’ handmaidens, but in others professionalism needs to be defended from politicians who endorse George Bernard Shaw’s description of professions as “a conspiracy against the laity”, seeking to micro-manage and infantalise them.
Finally, there is a need to address the challenge of life-long learning, although hopefully not going down the incredibly prescriptive, bureaucratic, and probably unworkable model of revalidation being developed for doctors in the UK.