BOOK REVIEWS 85 for public health pass it by. For those who want to know about water supply and health this book is essential reading.

STEPHEN J. WATKINS Director of Public Health

Stockport Health Authority, UK

M.E. COWART and W.J. SEROW, Nurses in the Workplace, Newbury Park: Sage Publications, 1992, 304 pp. Price E35.50.

The shortage of nurses in the USA is the theme of this edited collection of papers, covering topics such as supply and demand trends, political climate and policy analysis, and state policies and legislation.

The main focus of the book is the Florida situation, although this seems to reflect in many ways the general position in the USA. Shortages of nurses bite more deeply in Florida because of the larger than usual numbers of elderly people in the population and because of seasonal variations in the need for nurses resulting from the transient holiday-making clientele.

In addition to these factors, attention is drawn to increasingly sophisticated biotechno- logical techniques which create demands for more treatments, decreases in length of patient stay leading to more highly dependent patients, and changed insurance reimbur- sement practices imposing more stringent conditions on what can be charged.

From this point of view of nurses, there is great dissatisfaction with levels of pay, which are more similar to those of blue-collar workers than other professionals, to lack of autonomy at work, the need to work shifts, and lack of a clear career structure. These problems have led to declining recruitment to nurse education programmes at both graduate and non-graduate levels. Where ‘assistive personnel’ have been brought in to substitute for trained nurses, quality of care has declined and time savings have not necessarily resulted because of the need for trained nurses to supervise the alternative staff. Similarly, the use of temporary agency staff detracts from continuity of care and does not contribute towards a feeling of cohesive team work.

‘Work restructuring’ is the solution proposed by many contributors to the volume. Previously, recruitment strategies have focused on pay rather than conditions, but this emphasis is reversed and career goals of potential recruits are addressed. Work is rede- signed so that an all-registered nurse workforce is employed. This is cost-effective in terms of decreased costs and length of patient stay. Staff satisfaction increases and turnover, with its associated costs for advertising and recruitment, is reduced. Decentrali- zation is another key emphasis, with services such as pharmacy being based in smaller care units. Information services are developed to provide laboratory results and patient care information directly to wards. Some architectural modifications go along with these changes, so that nurses are grouped around smaller numbers of beds instead of having one nurses’ station or office for a large ward.

Nurse autonomy is developed by improving nurseaoctor collaboration so that nurs- ing roles are extended and the best use is made of nursing skills and expertise. Collabor- ation with nurse educators takes the form of more on-site education and part-time courses for nurses seeking to enhance their qualifications.

The usefulness and potential readership of the book will be determined by the health care and general economic context of potential readers. In the UK, for example, the position is quite different. Workforce planning predictions are currently leading to dra- matic cuts in numbers of students being recruited to nursing courses. This is occurring despite fears that declining numbers of school leavers would lead to recruitment difficul- ties. Over-training seems to have occurred in the past, and closures of large mental hospitals and mental handicap hospitals have reduced staff needs. Skillmix is under consideration, with substitution of auxiliary workers for trained nurses.

86 BOOK REVIEWS

In other ways there are similarities between the USA and European situations, particu- larly with regard to quality of care. Several studies have now demonstrated that the employment of registered nurses is cost-effective and leads to higher levels of care, and the recent UK clinical grading exercise was an attempt to provide a clearer structure and better rewards to those opting for a clinical career.

The most significant issue to emerge from the book for me is the universality of nurses’ demands for greater respect and rewards for their skills, together with acknowled- gement that expert nursing contributes strongly to positive patient outcomes as well as a cost-effective service.

CHRISTINE WEBB Depur tmen t of’ Nursing

Munchester University, UK

R.A. WILSON and J.A. STILWELL (Eds) The National Health Service and the Labour Market, Aldershot: Avebury (Ashgate Publishing Company), 1992,320 pp. Price 535.00.

This book publishes the results of research commissioned by the Department of Health in the UK, examining the labour market for nurses, professions allied to medicine (PAMs) and support workers. The 13 chapters (together with a useful ‘key points’ summary) cover: general supply and demand issues; a survey of relevant research; appli- cation of labour force survey data; a review of conditions of employment issues and career aspirations; and, lastly, a detailed case study examining the question of ‘mothers as student nurses’.

A book of this nature does not make light reading. It is very detailed, packed with pages of tables and data. What emerges are some important statistics, trends and themes which are highly relevant to workforce planning-a term the editors properly regard as considerably more appropriate than ’manpower’ planning in relation to a largely female workforce.

The demographic timebomb (‘ticking or defused?’) rightly receives detailed attention, both in regard to increasing demand for NHS services and in respect of labour supply. Some of the issues are well known to personnel practitioners; for example, the high percentage of the labour force drawn from the young, female, five GCSE segment of the market.

But the book highlights less well-known aspects: the increase for example, in 16-year- olds from ethnic minorities in 1995 (against the overall trend) with the obvious impli- cations for maintaining a balanced workforce. The conclusion of the research presented here is that the deep recession of 1990-1991 has caused a considerable slack in the labour market, but that in the longer term this may be no more than a temporary reprieve.

The logical order of the chapters warrants little comment. But working through the chapters, particular themes emerge. The first, which consistently occurs on even a cursory reading, is the need to get to grips with equal-opportunity issues in order to address questions of supply and demand. Just some of the issues are the need to move away from the ‘young female’ supply; the need to address the comparatively poor career progression prospects for women compared to men; and, the need to tackle inertia in training schools which are still locked into full-time education.

The need to challenge traditional patterns of skill mix also becomes evident, including a challenge arising from the research to look hard at the established boundary between doctors and other staff groups. The research also highlights a dilemma in nursing skill mix, whereby the more expert registered nurse can theoretically devolve more to unskilled workers; whilst, on the other hand, the professional model of ‘holistic’ nursing implies more patient contact requiring more trained nurse time. The research also highlights the drive towards greater professionalism-and higher qualifications-amongst both