Shortage of intensive case nurses is a key healthcare blockage here

AN RTÉ newsreader, at the races and well tore into the bargain, suddenly remembered he was due in studio 20 minutes later to read the 6.30pm news.

He asked the guards to help. Up went the blue lights. On went the sirens. (Bring up the sound of screaming tyres.) Still well-tore, but now in a squad car, the newsreader composed himself. Arriving at the studios with minutes to spare, he concentrated on projecting serious sobriety. The red light came on. He read the bulletin, start to finish, perfectly. Then he turned to the weather forecast. "The north of Ireland," he intoned, "is moving in a southerly direction."

It was a long time ago and the statement wasn't true. But a version is happening in the US right now. The north of America is moving in a southerly direction. The populations of warm cuddly states such as Florida are growing enormously.

The southward drift is not just retirees. It's everybody who's fed up of bitter winters. Including my friend's sister, Betsy, who started work this week.

When I was introduced to Betsy a fortnight ago, I asked her if she anticipated any problems getting a job. All the people present laughed and told her to tell me her job-seeker story.

"I was passing Lee Memorial Hospital," she said, "and I went in on impulse to ask for a job-application form."

Hand hovering over the different forms, the woman at the recruitment desk asked Betsy which she needed.

"I'm an intensive care nurse," Betsy said.

The woman went from apathy to frenzy in 10 seconds. Out of the chair. Out from behind the desk. She sort of patted Betsy down and got a promise out of her that she wouldn't leave. Within minutes, Betsy (mortified because she was in jeans and a T-shirt) was sitting in front of the director of nursing, totally unprepared for the interview she was undergoing. Twenty minutes later, she not only had the job, but the director of nursing was wondering aloud if Betsy really needed to go home that evening - wouldn't she like to go through induction training straight away?

That's what it's like to be an intensive care nurse these days in one of the wealthiest states in one of the wealthiest countries in the world. Yet when surgery is postponed in Ireland for lack of intensive care nurses, we start looking for someone to blame.

(I should state, upfront, at this point, that I advise several hospitals in the public and private sector, and none of them know I'm writing this.)

Here's the outdated perception: You have to pay consultant surgeons a king's ransom because their intervention saves your life or makes your life liveable.

Here's the perception that needs to take hold: there's damn all point paying a king's ransom to consultants if the shortage of nurses, particularly specialist nurses, means they can't do their job. (And no, I do not advise the Irish Nurses' Organisation and have never met Liam Doran.)

The State makes agreements with medical and other service suppliers, based on all sorts of abstruse calculations and emotionallyfreighted negotiations with representative bodies. Seems to me that there's now a case of "never mind the reality, feel the established practice" about this model of approach.

Out in the private sector, it's simpler. When a plumber or an electrician is needed, either because your loo is blocked or your lights are out, you don't start with the architect. You start with the plumber or the electrician. And you pay whatever will get the loo going again or the lights to come on.

The worldwide shortage of intensive care nurses is remarkably absent in luxury clinics devoted to plastic surgery, because they pay over the odds.

But of course, it's not that simple. More training of more nurses is a priority in all countries with growing and/or ageing populations. Ireland has embarked on radical expansion of such training and former Health Minister Micheál Martin might want a bit of credit for that, but since he's going to spend the next two years swanning around opening plants and announcing jobs, he can do without a plug on the nursing front.

However, even an expanded number of nurses coming into the system will not, in the short to medium term, dent the ICU problem. This isn't a bums-on-seats issue.

One of the complicating factors is that, after basic training and the extra specialist training opted for by aspirant ICU nurses, the burnout rate for this kind of work is much higher than for ward nursing. ICU nurses are dealing with patients who rarely know who's taking care of them. Patients compromised by trauma and major surgery to an extent that robs them of consciousness, the capacity to communicate, and most of what individuates a human being.

TO STAND in an ICU is to witness more science than is in play on the flight deck of the most modern airliner and more concentration on cleanliness than is required in those electronic production plants where everybody wears space suits. In the midst of this brightly-lit bleeping technology, patients lie, intubated, disoriented, comatose or terrified. And inevitably, in the words of the old Yeats ballad, it's a place where people die and die.

In paediatric ICUs, the pressure on nurses is worse. A sick, suffering toddler cannot have it explained to him or her that this, too, will pass. A sick, suffering toddler who doesn't make it is a source of immeasurable personal grief to the nurses who cared for the child. They take out the tubes. They gently remove the tapes. They wrap the little one in soft pastel baby blankets and watch distraught parents cradling their pathetically light and immeasurably heavy burden.

If an ICU patient - child or adult - is lucky enough to get out of danger, they move out and rarely remember the nurses who pulled them through the bad times.

It is a world of concentrated care delivered to patients who can intellectually and in retrospect appreciate what was done for them, but who can never develop the relationship with the carer appropriate to the indebtedness.

The inevitable level of burnout is complicated by the fact that, although nursing is a two-gender profession, it is still dominated by women. Intensive care nursing becomes more and more difficult when the nurse has children at home and perhaps an ageing parent who needs support. Job-sharing in general nursing is a given. Job-sharing in intensive care is less prevalent.

In addition, the brightest and best nurses in ICU now have a possible career path never envisaged by nurses in, say, the '80s. Degrees in hand, they can move out of nursing into healthcare administration or general management.

As yet unaddressed is the moral hazard implicit in the developed world's assumption that it's fine and dandy to steal nurses from the developing world. There's been a great deal of high-minded guff in the past few days about development aid to the third world and nary a mention of the contradiction implicit therein: give them the funds to develop their education systems so that they will have, among others, highly qualified nurses.

And then steal the nurses...