Data and nurses

There is a nasty bind when it comes to managing things using information. You have to collect and report the information. Which takes time and money. And if you haven’t got any of that to start with…

I wrote this a while ago and then I read this amazing post by Militant Medical Nurse on the hard realities of the pressure faced by nurses [NB. Not entirely suitable for work - our dear nurse is a bit lot sweary].

Unfortunately I wrote before I read, or I might have written differently. No, I would have written differently. What I read in the Militant Medical Nurse blog has really shaken me. Hearing that sort of detail coming from the frontline. Not as an exceptional “oh we’ve just had a major emergency or epidemic” story but as a regular, 24/7 catalogue of reality.

And suddenly the most important statistic I’m interested in about a hospital has changed. It’s not the “mortality index” (whatever that may tell me). It’s not the individual performance of a surgeon who might operate on me (though that’s clearly interesting).

It’s the ward-level ratio of Registered Nurses to patients.

And can I find it? Not on NHS Choices, I can’t. Not in the digest of stats at the NHS Information Centre, I can’t. I can find workforce data which might help if cross-referenced with patient volumes data, but I can’t find real, live, granular data that tells me how things really are.

But what statistics do I actually want? A day-by-day report? No, that seems like a disproportionate burden to add to already-stretched hospitals. Weekly then? Or perhaps an annual average? And what sort of level of detail will be required: my instincts tell me that ward level is the one to watch. Our blogging nurse writes compellingly about the differences between surgical and medical wards, about the impact of long-stay geriatric patients and the “booting out” of harder-to-care-for patients towards general medical wards. And ultimately, were I to be admitted, ward level is where I’d be. The staffing there is what I’d care about.

But what would ward-level statistics actually consist of? Census-style, a snapshot of who was actually present at a particular time? Seems daft, and a bit arbitrary. What then of the difference between the number “supposed” to be there, and the number who’ve actually shown up? Not off-sick that day, or detached to another ward to cover for a short time. How do we count nurses who might always be shared between wards? What about vacant posts, either frozen or part-way through recruitment? As ever, it gets complicated quickly, doesn’t it?

And I know I’ve gone for Registered Nurses, as Militant Medical Nurse has written so eloquently about their capabilities, but what if the skills are actually there, in another form of specialist nurse? Lots of them, maybe. I’d see a statistic that didn’t tell me what I really wanted to know – whether or not I’d have a nightmare getting a blanket or having a tube flushed out.

In the same way that MMN’s troublesome relatives are there, persistently asking for more and more information about Grandad’s condition, so am I – just from behind a keyboard, or a blog, or some FOI requests, miles away.

I’m still claiming my entitlement to data – I’m interpreting the phrase du jour of “an information revolution” to mean just that – and the ability to make my choices (as a patient or a lobbyist) based on real information.

I’m asking for it, raw and unfiltered, all to be easily available in one place. I’m asking for quite a lot of work to be done there. Am I entitled?

And at this point someone usually says: “Ah, but the hospital has all this information anyway. They must have. They should just release it.”

Bad news: because some tosser in a suit (actually, probably not a suit these days) can draw a box on a flipchart marked “HR information system” with a wiggly arrow coming out of it and pointing towards a craply-drawn cloud thing labelled “the Internet” it doesn’t actually follow that it’s true, sensible or even possible.

There is a lot of work involved here, a lot, in data definition and in information engineering, to achieve something that can be glibly said in a few seconds. We need to be careful of that.

In reality, I know that data collection isn’t done the way it would need to be, that interpretation of “where” a patient actually is for treatment purposes (ward, building, clinic, specialism, theatre etc.) isn’t consistent, that miscoding is prevalent, and so on.

Anyway, let’s step back for a second. I’ve been all nice and cool and rational about this. Setting out a hypothesis that there are nursing skills shortages of a particular type in particular areas, and then calmly looking for open data to highlight where. (That is generally how I roll.)

This evidence might, possibly, in time, lead on to the identification of why the problem exists, systematically, and provide either management insight or lobbying pressure to do something about it. Yeah yeah yeah.

What a load of bollocks. Militant Medical Nurse says there aren’t enough nurses. There aren’t enough nurses. Uneaten food, chaotic cleanliness, delayed painkillers say there aren’t enough nurses. There aren’t enough nurses.

The testimony of medical nurses, militant and otherwise: that should count for something, right? And what about patients? I understand that Granny’s soiled bed is a rationally lower priority than an emergency transfusion form, but when did we come to accept indignity at that level at all?

Why waste time with tossers in suits (and, indeed, flipcharts) when you could just set a ratio that works as your operating baseline, and build your model around that? Report and manage the exceptions to that baseline, sure, but why wait for the data to “prove” anything. The Royal College of Nursing, it seems, are on to this question of ratios, by the way. More power to to them. Support them however you can.

And there lie some questions: does the cause need the data? Does the search for data delay the obvious? Could the open data revolution sometimes obfuscate more than enlighten? While we’re arguing over reporting standards, boundary definitions and data feeds, real people are hurting and starving.

And that’s making Militant Medical Nurse, and me, very angry.

(with big thanks to Justin Kerr-Stevens, and the NHS Choices team, who supplied links and information for this post)

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10 Responses

  1. Like you, I read that MMN post a while ago and it changed my conception of geriatric nursing entirely. The idea that there could be such a constant, horrendous stream of emergencies and so few people to deal with them – knowing that, suddenly the questions you want to ask of the data change, and suddenly the data just isn’t there to answer them in any meaningful way.

    But the people are, and even if the data’s not there in numerical, hard form, front line nurses already have incredibly strong anecdotal evidence supporting the conclusion that if staffing levels are low, then people suffer. I share your anger that the focus is on the numbers when in this case it seems like the answer is obvious.

  2. Colin says:

    During my pre redundancy career in the NHS, 1974-1993, each ward kept a weekly rota showing the nurses to be on duty. It was marked to show any changes and to confirm attendance. Simple and effective data.

  3. Anonymous says:

    Thanks Paul. I hope there is a way to get this data, and the will to share it.

  4. Paul Johnston says:

    Paul – Interesting post and the Militant Nurse piece is certainly incredibly powerful. What struck me is that a lot of the problem is about how we organise things, not just lack of resources. Is the rule that says two RNs are needed to authorise use of the drug appropriate? Is the way we have organised doctors and nurses (as two warring tribes) sensible? Is all our emphasis on competition and measurement to improve performance the right way to go? My reaction to Militant Nurse is the fantasy of getting together a couple of hundred people with medical (and other) skills and building a hospital from scratch where none of the old rules about how everything had to work were taken for granted. Abolish everything starting with the title doctor, nurse and perhaps even patient!

  5. Tim Davies says:

    Hey Paul. Insightful, grounded and passionate thinking as always.

    Some reflections inspired by your post over on MADwData site here: http://www.madwdata.org.uk/blog/2011/02/25/sprinkled-stats-and-the-search-for-data – and will do more thinking in advance of upcoming Open Data Campaigning Camp about the differences between ‘data backed’ and ‘data guided’ campaigning, and ‘data-driven’ campaigns or ‘data-based’ campaigning which falls into the trap of waiting for data you note above…


  6. [...] access to raw data to slice and explore it in different ways, can be tricky. And as Paul Clarke questions in a blog post today, is getting the data always the most important part of campaigning for a change? Whilst we might [...]

  7. Anonymous says:

    Thanks Colin – yes, simple, local data. Straightforward to record, and locally, easy to access and interpret. The damn internet has buggered everything up now, of course ;) – the potential to aggregate data requires standards, and a whole load of other process and machinery never needed in previous days.

  8. Graham says:

    I think this is even more fundamental than data. I think this is about power. We have a culture being built on thought – power, money and status go to those who think, not do. Making a decision is seen as more important than doing. The virtual trumps the physical because imagination is easier than implementation.

    We outsourced all our doing centuries ago. Our lives are based on having other people do stuff for us, and then buying services back so we have to know as little as possible. We decide what to buy. Someone else makes all the options that are available to us. We decide what to make. Someone else makes it for us.

    The “frontline” (a horrendous term) is a cold, dirty place. We’re intent on getting out, on escaping to the colony worlds, the new worlds, the Internet, the countryside. Doing stuff is so… manual, so working class. Reality is for the poor.

    Data can fit into this idea of implementation – in fact it’s vital, inherent, and probably already there. All this data is in people’s heads. Data is just a map for those who have no idea what’s really going on. Data is useful for explanation.

    But yeah, we need more than just data. We need understanding of what it means to actually use that data. To create that data.

    To *be* that data.

  9. The principle of usefulness of quantitive data versus qualitative in such situations? Do we have sufficient skilled statisticians to make sense of the former? Maybe that means that only anecdotal makes sense?
    I thought I’d seen some flexi-time machine last time I stayed in hospital – so if staff are logging in & out at start/end of shifts, there is a computer system that knows what types/grades of staff are in which department/ward when? It doesn’t know what tasks they do, but making the data anonymous & aggregating data from all hospitals ought to be relatively simple (unless, of course, none of the basic data has been standardised…).
    Making decisions based just on gut reaction to frontline experience would not lead to any better decisions than those based purely on data. Difficult decisions need compassion and perspective, clarity of information combined with humanitarian knowledge and understanding.

  10. Great post about what “compassionate open data” should be about. This doesn’t apply only to NHS, but to many other organisations and institutions, although for NHS is more evident what’s wrong with certain data releases.

    When NHS published their hospital mortality ratio, in the open data movement early days, someone realised that this was about “look at how good is your local hospital where no one dies”. Incorrect interpretation, if taken in a brutal quantitative way: the best, highly specialised, hospitals are those where mortality ratio is *high*, given they receive patients in very bad conditions.

    The problem with this kind of data is that it’s very difficult for administrators to identify ways to package and release qualitative information. This is partially due to the DPA, as at least some of the information in this context might allow third-parties to identify patients and staff. However, assuming we can find an impartial way of publishing qualitative data, I don’t see clearly how their mere release might help – surely it does not help reaching some level of objectiveness. Moreover, in a sense, data should always be quantitative, whereas their interpretation should be qualitative, the latter being always left to the user.

    Take the mortality ratio example: how would you release information that let users interpret the data correctly? Is mortality ratio augmentable by some other data release?

    What is not clear to me is if we want objective data or objective interpretations, assuming the latter can exist.

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