Royal College of Midwives               September 2020

 

Written evidence submitted by the Royal College of Midwives (WBR0025)

 

The Royal College of Midwives’ response to Workforce burnout and resilience in the NHS and social care

 

The Royal College of Midwives (RCM) is the trade union and professional organisation that represents the vast majority of practising midwives in the UK. It is the only such organisation run by midwives for midwives. The RCM is the voice of midwifery, providing excellence in representation, professional leadership, education and influence for and on behalf of midwives. We actively support and campaign for improvements to maternity services and provide professional leadership for one of the most established clinical disciplines.

 

The RCM welcomes the opportunity to respond to this consultation and our views are set out below.

 


 

Summary

Even prior to the COVID-19 pandemic, maternity units were overworked and understaffed. While the reduction in the birth rate has brought some relief, maternity units are dealing with increasing numbers of complex cases, the ambitious objectives of the maternity transformation programme, including in particular, the demands of the safety agenda and the transition to a midwifery continuity of carer (MCOC) model, and expanding public health and advocacy responsibilities. The impact of these increasing pressures can be seen clearly in the results of surveys conducted by both the RCM, the NHS, and external organisations, which reveal that midwives are frequently working additional unpaid hours and feeling unwell due to stress. Midwives are also suffering from disproportionately high levels of bullying and harassment.

The impact of the COVID-19 pandemic on an already overworked and under-supported maternity care workforce has been considerable. Maternity care is an emergency service, and as such, the maternity care workforce has limited ability to ration care in order to cope with staff absences, causing staffing shortages to worsen throughout the pandemic. Further, based on RCM surveys, midwives’ have had insufficient access to PPE, and midwives’ mental health has taken a hit. Midwives from BAME backgrounds have been particularly impacted, reporting considerable trauma, and a lack of support from employers who have largely failed to undertake appropriate risk assessments. Student midwives have also suffered after having their studies disrupted.

 

The impact of workforce burnout amongst the maternity care workforce is undeniable. Research indicates that midwives experience symptoms of anxiety and depression at higher rates than the general population. Midwives’ mental health is also likely to have worsened as a result of the COVID-19 pandemic, noting that 57% of midwives and MSWs, 64% of midwifery educators, and 97% of midwifery students feel the pandemic has negatively impacted on their mental health. In addition, although midwives try particularly hard to ensure their working conditions do not adversely affect the women they care for, there is strong evidence that poor mental health and wellbeing amongst staff impairs performance and the quality of care women receive.

 

Employing the Birthrate Plus® tool, the RCM estimates there is currently a shortage of at least 1300 midwives in England. As such, it is likely that at least 1300 additional midwives are required to reduce pressure on, and burnout amongst the maternity care workforce. However, given the physical and emotional toll the pandemic has taken, the maternity care workforce is likely to require additional support in order to recuperate. Also, it is possible that the Birthrate plus® tool will be adjusted in the near future, meaning this number could soon change.

 

The RCM has warmly welcomed a commitment by the United Kingdom Government to train 3,650 new midwives. The fulfilment of this commitment will be essential if we are to sure-up the future maternity care workforce. However, it is important to acknowledge that it will take a number of years for these midwives to materialise. There is also a concern that universities will be unable to support these additional training places. Based on the RCM’s FOI to pre-registration midwifery education providers in 2018, there is a continued downward trend in the number of midwifery teaching staff per institution. This is particularly worrying, given the likelihood that training places will increase as a result of the changes to A-level results. Further, RCM surveys reveal that midwifery educators are stressed, over-worked, and struggling to keep up.

 

The commitments made in the People Plan to create a more flexible, inclusive, and supportive workplace culture are appreciated. These changes will, if delivered, improve the working life and retention of maternity staff. However, the Plan contains no detail as to how these commitments will be delivered, nor the cost of doing so. Given the urgent pressures discussed, greater detail as to how and when these commitments will be delivered is necessary.

 

The following measures are recommended to tackle and mitigate the causes of workforce stress and burnout in the maternity care workforce:

  1. Ensure adequate pay
  2. Ensure optimum staffing levels, based on careful consideration of relevant factors
  3. Prioritise recovery
  4. Tackle the culture of blame
  5. Better financial support for student midwives entering the profession
  6. Reconsider COVID recruitment policies
  7. Ensure NHS employers take the menopause into account

 

 


Response

 

1.       How resilient was the NHS and social care workforce under pre-COVID-19 operating conditions, and how might that resilience be strengthened in the future?

 

Even prior to the COVID-19 pandemic, maternity units were overworked and understaffed. While the reduction in the birth rate has brought some relief, maternity units are dealing with increasing numbers of complex cases,[1] expanding public health and advocacy responsibilities, and the ambitious objectives of the maternity transformation programme (MTP), including in particular, the demands of the safety agenda, and the transition to a midwifery continuity of carer (MCOC) model. While these initiatives are well evidenced, they place considerable additional pressures on midwives, creating fertile ground for blame, bullying and harassment.

The impact of these increasing pressures can be seen clearly in the results of the NHS Staff survey, 2019.[2] That survey revealed that 34% of midwives felt they were unable to meet the conflicting demands on their time at work and 79.6% were working between 1-11 additional unpaid hours per week. In addition, 40.3% of midwives reported feeling unwell due to work related stress in the previous 12 months, and in the same period, 63.7% had continued to come to work despite not feeling well enough to perform their duties.

Surveys conducted by the RCM also demonstrate the demands on the maternity care workforce and the resultant impact on morale. For example, a survey of Directors and Heads of Midwifery (D/HOMs) conducted in March 2020 revealed that 54% of D/HOM’s funded staffing was below recommended levels; and 74% were having to redeploy staff at least once per week to cover essential services. As the likely result of these pressures, 72% reported that morale was ‘ok’ or ‘poor’.[3]

The recently published report by Supporting Occupational Health and Wellbeing Professionals (SOM) also demonstrates the impact these pressures are having on midwives’ mental health and wellbeing. That publication reported that midwives and nurses are at considerable risk of work-related stress, burnout and mental health problems as a result of heavy workload, lack of support, low job satisfaction (particularly in relation to terms and conditions of employment), low satisfaction with work-life balance, and the demands of providing compassionate care.[4]

The UK WHLEM study of midwives also returned similar findings.[5] That report found that there were high levels of emotional distress, as well as burnout (67%), anxiety (38%) and depression (33%) amongst midwives, primarily due to limited resources and support. As a result, an unusually high number of midwives (66.6%) had considered leaving the profession.

Midwives are also at a particularly high risk of bullying and harassment when compared to other NHS professions, which connected to the high-pressure environment in which midwives work. In 2019, 39.3% of midwives had experienced at least one incidence of bullying or harassment from patients in the previous 12 months compared to only 28.5% of NHS professionals as a whole, 15.2% of midwives had experienced bullying and harassment from managers, compared to 12.3% of NHS professionals, and 22.8% of midwives had experienced bullying and harassment from other colleagues, compared to 19% of NHS professionals.[6] Bullying, harassment and discrimination is also a particular problem for BAME midwives. In 2019, a shocking 42% of midwives reported experiencing discrimination based on their ethnic background.

 

Midwifery students are also struggling, which is undermining the resilience of the future maternity care workforce. An RCM survey conducted in 2019 revealed that 80% of students have reported feeling financially precarious, and 68% reported they agreed with the statement ‘I worry so much about money that it affects my studies’. Further, more than one third of students rated their mental health as ‘poor’ or ‘very poor’, and a similar percentage reported having to take time off due to poor mental health. Most concerningly, 70% of students had considered ending their studies.

 

As has been illustrated, even prior to the COVID-19 pandemic, the maternity care workforce was struggling. Strengthening the resilience of the maternity care workforce will require urgent action. Some necessary actions have been outlined in the People Plan, including those around improving flexibility, and tackling discrimination, bullying and harassment. However, additional actions will be required. These include ensuring optimum staffing levels in maternity teams, appropriate adjustments to pay, and better financial support for student midwives entering the profession.

 

2.       What has the impact of the COVID-19 pandemic been on resilience, levels of workforce stress, and burnout across the NHS and social care sectors? What is the current scale of workforce burnout across NHS and social care?  How does it manifest, how is it assessed, and what are its causes and contributing factors? 

 

2.1 The impact of the pandemic on resilience, levels of stress, and burnout; the current scale of burnout; its causes and contributing factors.

 

The impact of the COVID-19 pandemic on an already overworked and under-supported maternity care workforce has been considerable. Based on RCM tracking surveys, during the pandemic, staffing shortages in most NHS trusts doubled. In addition, as maternity care is an emergency service, the maternity care workforce has limited ability to ration care in order to cope with staff absences. As a result, during the COVID-19 period 87% of midwives reported having delayed using the toilet due to lack of time, over three quarters of midwives skipped meals, and over half of midwives reported feeling dehydrated ‘most’ or ‘all of the time’ at work. Considering these statistics, it is unsurprising that 57% of midwives and MSWs, 64% of midwifery educators, and 97% of midwifery students have also reported that the pandemic has negatively impacted on their mental health.[7]

 

Another key factor which has impacted on midwives’ stress and wellbeing throughout the pandemic has been the lack of adequate personal protective equipment (PPE) and testing. According to an RCM survey conducted in April, over half of midwives reported feeling unsafe when carrying out home visits due to fear of exposure to the COVID-19 virus, and lack of appropriate PPE.[8] That survey also found that under a third of midwives and MSWs who reported suffering symptoms of COVID-19 had been tested. Of those who did receive a test appointment, more than 20% had to travel over ten miles from their home to reach testing facilities.

 

Throughout the pandemic, midwives have also struggled to cope with the need to limit some services, for example home birth services. As midwives typically strive to facilitate women’s choices, the inability to do so caused considerable stress. The need to constantly be reassuring anxious women also created an additional burden. This situation was worsened by the publication of poorly evidenced guidance by the UK government on the dangers of contracting COVID-19 during pregnancy. This guidance was published without consultation with the relevant Royal Colleges.

 

Staff from BAME backgrounds have been particularly impacted by the pandemic. BAME staff, who are more likely to both contract and die from COVID-19, report feeling traumatised by the disproportionate impact of the virus. These fears were compounded by concerns over risk assessments. Despite advice from both ourselves[9] and NHS England[10] which directed NHS Trusts to conduct risk assessments for BAME staff working in patient facing roles, a recent investigation found that only 23% of Trusts had done so.[11] This is particularly problematic as BAME staff are less likely to speak up where they are treated unfairly in the workplace.[12] There is also some evidence that requests by BAME healthcare workers requests for PPE were more likely to be refused,[13] and that BAME healthcare workers have felt more pressure to work with COVID patients (63%) as opposed to their white counterparts (33%).[14]

 

Midwifery students have also faced additional hardship as a result of the pandemic. According to an RCM survey conducted in July, 97% of midwifery students feel the pandemic has impacted on their ability to study. This is inclusive of first year students, who were required to move to primarily virtual learning environments, and second- and third-year students, 50% of whom had their clinical placements ended. Of the 70% of second and third years who were later deployed into the workforce, 21% were still waiting to be paid, and only 30% of third year students had received job offers. Given the disruption and uncertainty students have faced it is unsurprising that a staggering 97% of students reported experiencing mild to moderate mental health problems since the pandemic began.

 

To make matters worse, currently the vast majority of midwifery leaders in NHS Trusts have no access to the board. This means the midwifery voice often goes unheard, and Trust boards are unaware of the concerns of, or pressures on maternity services. As a result, problems within maternity services are slow to be resolved, to the disbenefit of the maternity care workforce and service users.

 

2.2 How is burnout assessed?

Currently, burnout amongst the maternity care workforce can be measured by reference to the NHS Staff Survey, and supplemented by surveys undertaken by the RCM, as well as external organisations like SOM.

3.       What are the impacts of workforce burnout on service delivery, staff, patients and service users across the NHS and social care sectors?  

 

Impact on staff

 

The impact of the pressures midwives face at work are considerable.[15] Research indicates that a considerable number of midwives struggle to manage anxiety and depression, and experience symptoms of anxiety and depression at higher rates than the general population.[16] This is likely to have gotten worse following the COVID-19 pandemic, noting that 57% of midwives and MSWs, 64% of midwifery educators, and 97% of midwifery students feel the pandemic has negatively impacted on their mental health.[17] In addition, a high proportion of midwives have considered leaving the profession as a result of working conditions, high workloads, and inability to provide the standard of care required.[18]

 

Impact on patients and service users

 

The SOM report revealed that midwives try particularly hard to ensure that their working conditions and any stress they may experience does not adversely affect their patients.[19] Nevertheless, there is strong evidence that poor mental health and wellbeing among staff impairs the performance of healthcare professionals and the quality of care patients receive.[20] This is because staff who are burnt out are at increased risk of error making, and are more likely to suffer from low engagement (lack of vigour, dedication and absorption in work), cynicism, and compassion fatigue. [21] It should be noted that midwives are at particularly high risk of moral distress if institutional pressures and constraints stop them from pursuing what they believe to be the most appropriate course of action for their patients.[22]

 

Impact on service delivery

 

The financial implications of unacceptable working conditions and poor wellbeing among nurses and midwives are difficult to measure. However, the link between work engagement and the financial performance of NHS Trusts has been highlighted in a report by the King’s Fund,[23] where a change of one standard deviation on the 2015 NHS Staff Survey engagement measure was associated with a saving of £1.7 million on annual agency staff costs for the average Trust. In addition, the cost of bullying and harassment to the NHS in England has been estimated to be £2.281 billion (inclusive of sickness absence (£302.2 million), sickness presenteeism (£604.4 million), employee turnover (£231.9 million), productivity (£575.7 million) as well as industrial relations, compensation and litigation costs (£83.5 million).[24]

4.       What long term projections for the future health and social care workforce are available, and how many more staff are required so that burnout and pressure on the frontline are reduced? To what extent are staff establishments in line with current and future resilience requirements? 

 

In England, appropriate staffing levels for maternity units are calculated based on the Birthrate Plus® tool.[25] Birthrate Plus® is the only credible workforce planning tool for midwifery and is endorsed by NICE. Employing the Birthrate Plus® tool, the RCM estimates that there is currently a shortage of at least 1300 midwives in England. Our assessment of this shortage is reinforced by consecutive surveys conducted by the RCM of Directors and Heads of Midwifery (D/HOMs). These surveys reveal worsening staff shortages across England. For example, in 2019, 48% of D/HOMs reported that their funded staffing was below recommended levels, increasing to 54% in March 2020; and 79% of HOMs had midwife vacancies, rising to 80% in 2020.

 

As has been discussed, the pandemic has significantly worsened staffing shortages and therefore pressures on midwives. Over the coming months, there will be ongoing staffing pressures and continued need for some staff to be shielding or working in non-patient facing roles. Given the physical and emotional toll the pandemic has taken, the maternity care workforce will also require additional support to recuperate. Of course, this will be particularly important if there is a second wave.

 

In addition, the Nursing and Midwifery Council (NMC) reports that although there has been a larger than average increase in midwives and nurses joining the permanent register, this increase is largely accounted for by nurses and midwives from outside the EU. As a result of the pandemic and subsequent travel restrictions, it is unlikely the UK will be able to continue to rely on professionals from these areas at least in the short term.[26]

 

The Committee should also be aware that the RCM will be meeting with Birthrate Plus® in the near future to discuss any necessary updates to the methodology, which may impact on the assessment of the shortage of midwives going forward.

5.       To what extent are there sufficient numbers of NHS and social care professionals in training for service and resilience planning? On what basis are decisions made about the supply and demand for professionals in training?  

 

In 2018, the UK Government committed to train 3,650 more midwives.[27] The fulfilment of this commitment will be essential to sure up the future maternity care workforce. However, it is important to acknowledge that it will take a number of years for these midwives to materialise. Particularly as the number of midwives joining the profession must be balanced against the number of midwives leaving, which has increased significantly as a result of Brexit, and may increase further as a result of continuing poor pay and conditions, and the impact of the COVID-19 pandemic.

 

In addition, the RCM is concerned that as a result of the COVID-19 pandemic, students from the current cohort will be delayed in graduating, as they attempt to catch up with their studies. It is also possible that general attrition will increase as a result of the hardships students are experiencing, which are inclusive of the demanding nature of a midwifery degree, the financial burdens discussed above, and the compounding impact of the disruption caused by the pandemic. These issues could be significantly worsened by a second wave.

 

The Committee should also be aware that there is a concern that universities will be unable to support these additional training places. Based on the RCM’s FOI to pre-registration midwifery education providers in 2018, there is a continued downward trend in the number of midwifery teaching staff per institution.[28] This is particularly worrying, given the likelihood that training places will increase as a result of the changes to A-level results. Further, based on an RCM survey conducted in August 2020,[29] 50% of midwifery educators report feeling stressed ‘every day’ or ‘most days’, nearly 40% of midwifery lecturers report working more than 8 additional unpaid hours per week, and 91% report having felt unwell due to work related stress in the past 12 months.

6.       Will the measures announced in the People Plan so far be enough to increase resilience, improve working life and productivity, and reduce the risk of workforce burnout across the NHS, both now and in the future?  

 

The RCM appreciates the commitments made in the People Plan (‘the Plan’) to create a more flexible, inclusive, and supportive workplace culture. These changes will, if delivered, improve the working life and retention of midwifery staff. However, the Plan contains no detail as to how these commitments will be delivered, nor the cost of doing so. Given the urgent pressures discussed, greater detail as to how and when these commitments will be delivered is necessary. In addition, there are several issues the Plan does not address, which are set out below.

7.       What further measures will be required to tackle and mitigate the causes of workforce stress and burnout? 

 

The following measures are recommended to tackle and mitigate the causes of workforce stress and burnout in the maternity care workforce:

7.1 Ensure adequate pay

Midwives and MSWs work exceptionally hard to deliver safe, high quality care. Throughout the COVID-19 Pandemic, the maternity workforce has worked even harder, demonstrating professionalism and commitment to supporting women and their babies despite numerous challenges, including service reconfigurations and staff shortages. Midwives and MSWs deserve to be appropriately compensated for their work. Appropriate and fair compensation is not only necessary for job satisfaction, which can lessen stress and burnout, but also to retain and attract the best people to the NHS. We will continue to call on the Government to bring forward a pay deal set for April 2021, and to negotiate a much more substantial increase for midwives and other NHS staff.

7.2 Ensure optimum staffing levels, based on careful consideration of relevant factors

As discussed, the shortage of midwives is taking an incredible toll on the maternity care workforce. These issues have been compounded by the COVID-19 pandemic. It is no longer feasible to rely on the good will of midwifery staff to plug gaps in the workforce by working additional unpaid hours, on top of an already demanding job. Urgent action is required to address the shortage of midwives, and any targets should be based on an assessment of all relevant factors including increasing complexity, expanding public health and advocacy responsibilities, and the ongoing transformation of maternity services.

7.3 Prioritise recovery

The COVID-19 pandemic has taken a huge physical and mental toll. Different areas of the UK will experience different levels of impact from the ongoing pandemic. Some maternity services will have had midwife led units that have been requisitioned for use for COVID patients and some areas will have paused homebirth services. The restoration of these midwife led care settings will be needed to be approached carefully, as will any resumption of maternity transformation activities. The maternity care workforce will need a period of recuperation, and it is vital that the mental health of the maternity care workforce is prioritised.

 

7.4 Tackle the culture of blame

 

Although there is a welcome focus on implementing a learning culture in the Plan, additional focus is needed to address the ‘blame culture’ in the NHS. NHS workers, including midwives, are often blamed and demonised when things go wrong, even though the fault often sits with an overstretched healthcare service. This problem is compounded by the media. NHS employers must work to counter ‘blame’ both within the NHS and in the media.

 

7.5 Better financial support for student midwives entering the profession

 

Midwifery students are struggling. According to RCM surveys, following the cancellation of the bursary and the introduction of tuition fees in 2017, students have struggled to make ends meet, and it is taking a toll on their mental health. Now the additional disruption caused by the pandemic will make things even harder. Efforts to increase resilience amongst the maternity care workforce are futile if they do not start at the beginning. We must ensure our students are properly supported to receive high quality training. The RCM is calling for a review of financial support for students and the provision of maintenance grants which reflect actual student need.

 

7.6 Ensure NHS employers take the menopause into account

 

The Plan should also highlight the need for flexible working to support women through menopause. Women make up more than 50% of the NHS workforce, and 99% of the midwifery workforce. The symptoms of menopause can cause significant and problems for women at work.[30] Women who are experiencing the menopause require support and understanding from their line managers as well as the flexibility to make necessary adjustments. Menopause is a health condition and should be treated as such. Doing so will benefit the NHS by creating an environment in which female NHS workers are supported to perform at their best.

 

7.7 Reconsider COVID recruitment policies

During the pandemic, 14,000 former nurses and midwives joined the Nursing and Midwifery Council’s emergency register in order to assist with the response to the pandemic. Of this number, an extraordinarily small number of midwives were actually deployed into the workforce. The UK government needs to have a strategic plan in place in order to support the successful deployment of staff returning to an emergency register in the future. Appropriate escalation policies and better planning is necessary if this additional support is to be effectively mobilised in the event of a second wave.

 

 

 

 

 

Royal College of Midwives

Sept 2020

 

 

 

12

 


[1] For example, more women are having children in their late 30’s and early 40’s, and more women are presenting as obese at their first booking appointment.

[2] NHS Survey Coordination Centre (2019) NHS Staff Survey Results. Available at: https://www.nhsstaffsurveys.com/Page/1085/Latest-Results/NHS-Staff-Survey-Results/

[3] Royal College of Midwives (2020) Half of maternity units understaffed say new survey. Available at: https://www.rcm.org.uk/media-releases/2020/march/half-of-maternity-units-understaffed-says-new-survey/

[4] Kinman. G, Teoh. K, and Harriss, A. (2020) The Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom. Available at: https://www.som.org.uk/sites/som.org.uk/files/The_Mental_Health_and_Wellbeing_of_Nurses_and_Midwives_in_the_United_Kingdom.pdf

[5] Hunter B, Fenwick J, Sidebotham M, Henley J. Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors. Midwifery. 2019;79:102526. doi:10.1016/j.midw.2019.08.008

[6] NHS Staff Survey (2019) NHS Staff Survey: Latest results. Available at: https://www.nhsstaffsurveys.com/Page/1085/Latest-Results/NHS-Staff-Survey-Results/

[7] Based on RCM surveys.

[8] Royal College of Midwives (2020) New RCM survey reveals more than half of midwives do not feel safe carrying out home visits. Available at: https://www.rcm.org.uk/media-releases/2020/april/new-rcm-survey-reveals-more-than-half-of-midwives-do-not-feel-safe-carrying-out-home-visits/

[9] Royal College of Midwives (2020) Equality essentials: Appropriate assessment during the current pandemic. Available at: https://www.rcm.org.uk/media/3939/risk-assessment-wraparound-guidance-a3-may-2020.pdf

[10] NHS Employers (2020) Risk assessments for staff. Available at: https://www.nhsemployers.org/covid19/health-safety-and-wellbeing/risk-assessments-for-staff

[11] Sky news (2020) NHS England apologises after investigation finds only 23% of trusts have risk assessed BAME staff. Available at: https://news.sky.com/story/coronavirus-nhs-england-apologises-after-investigation-finds-only-23-of-health-trusts-have-risk-assessed-bame-staff-12015363

[12] NHS Employers (2020) Risk assessments for staff. Available at: https://www.nhsemployers.org/covid19/health-safety-and-wellbeing/risk-assessments-for-staff

[13] House of Commons (2020) June 18 Debate (vol 677) Available at: https://hansard.parliament.uk/Commons/2020-06-18/debates/75FB1500-FB1E-424B-8A76-7F6518DB34A8/Covid-19BAMECommunities

[14] BMA (2020) Fighting the odds. Available at: https://www.bma.org.uk/news-and-opinion/fighting-the-odds-bame-doctors-at-greater-risk-from-covid-19

[15] Kinman. G, Teoh. K, and Harriss, A. (2020) The Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom. Available at: https://www.som.org.uk/sites/som.org.uk/files/The_Mental_Health_and_Wellbeing_of_Nurses_and_Midwives_in_the_United_Kingdom.pdf

[16] Ibid; Hunter B, Fenwick J, Sidebotham M, Henley J. Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors. Midwifery. 2019;79:102526. doi:10.1016/j.midw.2019.08.008

[17] Based on RCM surveys.

[18] Kinman. G, Teoh. K, and Harriss, A. (2020) The Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom. Available at: https://www.som.org.uk/sites/som.org.uk/files/The_Mental_Health_and_Wellbeing_of_Nurses_and_Midwives_in_the_United_Kingdom.pdf

[19] Ibid.

[20] Ibid; Picker, S and Raleigh, V (2018) The risk to care quality and staff wellbeing of an NHS system under pressure. Available at: https://www.nhsstaffsurveys.com/Caches/Files/Risks-to-care-quality-and-staff-wellbeing-VR-SS-v8-Final.pdf

[21] Ibid.

[22] Ibid.

[23] Ibid; Dawson J, West M. Employee engagement, sickness absence and agency spend in NHS trusts. 2018:1-24.  https://www.england. nhs.uk/publication/employeeengagement-sickness-absence-andagency-spend-in-nhs-trusts

[24] Kinman. G, Teoh. K, and Harriss, A. (2020) The Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom. Available at: https://www.som.org.uk/sites/som.org.uk/files/The_Mental_Health_and_Wellbeing_of_Nurses_and_Midwives_in_the_United_Kingdom.pdf; Kline R, Lewis D. The price of fear: Estimating the financial cost of bullying and harassment to the NHS in England. Public Money Manag. 2019;39(3):166-174. doi:10.1080/095 40962.2018.1535044

[25] For more information see: https://www.birthrateplus.co.uk/an-overview-of-methodology-and-its-development-within-the-uk/.

[26] Nursing and Midwifery Council (2020) Record numbers of registered nursing and midwifery professionals but potential stormy waters ahead, warns NMC. Available at: https://www.nmc.org.uk/news/press-releases/nmc-register-data-march-2020/

[27] Department of Health and Social Care (2018) Women to have dedicated midwives throughout pregnancy and birth. Available at: https://www.gov.uk/government/news/women-to-have-dedicated-midwives-throughout-pregnancy-and-birth

[28] In 2014/14 there were 13 students to every 1 FTE member of teaching staff, by 2018 this had decreased to 17:1.

[29] Please note these are preliminary results, as the survey had not concluded at the time of reporting.

[30] Royal College of Midwives (2019) Working with the menopause. Available at: https://www.rcm.org.uk/media/1892/equality_diversity_publication_working_with_menopause.pdf