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)