Written evidence submitted by The Royal College of Nursing (WBR0049)
The Royal College of Nursing is the largest professional body and trade union for nursing staff in the world. We represent 450,000 members who are registered nurses, midwives, students, and nursing support workers.
1.1. The nursing profession has been at the fore of the response to the pandemic, leading innovation and quality of treatment and care. Nursing staff play an indispensable role in delivering health and care services and they have gone above and beyond during this crisis to support and care for patients.
1.2. During the pandemic, many nursing staff have been involved in extremely stressful and traumatic situations. In the short term, health and care staff are focused on caring for patients, but the psychological impact of caring for increased volumes of very sick patients and distressed relatives, many of whom will be at very high risk or highly emotional, must not be underestimated.
1.3. Employers have a legal responsibility under health and safety legislation to provide a safe and healthy working environment. In the context of COVID-19, the impact and challenge of delivering care is likely to significantly affect an individual staff member’s mental health and wellbeing.
1.4. The risk of burnout during the pandemic has been high and the RCN has continually highlighted the need for nursing staff to be appropriately supported. The Society of Occupational Medicine defines burnout as having three components: emotional exhaustion, depersonalisation, and reduced personal accomplishment.
1.5. Striving to deliver high-quality, safe care in such adverse circumstances puts nursing staff at a heightened risk of developing compassion fatigue and becoming burned out.
1.6. Nursing is a safety critical profession and burnout poses a threat to the workforce and its wellbeing, and to patient safety as well. A meta-analysis of 21 studies concluded that there is an association between burnout and patient safety. Burnout was linked to a decline in patient safety and outcomes, and an increase in patient dissatisfaction and complaints.
1.7. The challenges presented by COVID-19 have added to the staffing pressures already faced by our health and care system. We continue to call for the expansion of accountability for workforce planning and funding in law, and investment in nursing higher education in England. A commitment in law is even more relevant now to provide assurance to our nursing community that workforce problems will be addressed in the long-term.
2.1. Employers must ensure that staff get a proper work/ life balance by recording and controlling excess hours, reviewing long and rotating shifts, enforcing working time regulations and encouraging staff to take rest breaks and annual leave.
2.2. Employers must provide counselling, occupational health, and specialist mental health services to which staff can self-refer. These services must be available to all nursing staff in all sectors, and all efforts must be made by government and employers to overcome barriers to accessing those services.
2.3. All nursing staff, working in all settings, must receive their full salary for COVID-19 related sickness absences, including for periods of self-isolation to protect themselves, other healthcare staff and their patients.
2.4. The significant workforce shortages in the NHS and social care must be addressed urgently. The Government must bring forward a fully funded, fully costed and modelled workforce strategy to ensure that the substantial gaps in the workforce are filled. This must be backed by accountability in law for staffing levels and sufficient workforce supply to meet these, in both the short and long-term.
2.5. To attract new nursing staff to the profession and support nursing staff to remain in the profession, the Government must commit to a 12.5% pay increase for all nursing staff covered by Agenda for Change terms, as part of a one-year deal that applies equally to all pay bands. This must be fully funded and not come from existing budgets.
3.1. Prior to the onset of the pandemic there were 50,000 nursing vacancies in the NHS across the UK, and Skills for Care estimated there were 122,000 vacancies in social care. The total number of registered nursing posts in adult social care has decreased by 1,000 in the last year. Since 2012, it has decreased by 10,400, which equates to a 20% decrease in England.
3.2. These workforce shortages result in unsafe staffing levels, which impact on patient safety as well as on the nursing staff themselves; leading to stress, moral distress and burnout. Unsafe staffing levels have been found to contribute to workplace bullying. They also impact on the ability of staff to take breaks and have well-designed working patterns, as staff are called in on their days off and cannot take enough rest days between shifts.
3.3. Furthermore, a lack of ‘space and time’ due to staffing capacity can compromise ability to attend wellbeing initiatives or for a nurse manager to be able to implement clinical supervision as a form of support for staff.
3.4. These significant workforce gaps are the background against which the resilience of the nursing workforce must be considered. Prior to the pandemic, our members were telling us that many of them were significantly overworked. In 2019, our Employment survey showed that 77% of nursing staff worked in excess of contracted hours at least once a week; 39% do so several times a week and 18% work additional hours on every shift.
3.5. Data from the 2018 NHS Staff Survey showed that 43.5% of the 127,564 registered nurses and midwives in England who responded reported feeling unwell due to work-related stress. Perceived stress was most frequent among the midwives that participated (51.6%), followed by mental health nurses (49.5%), health visitors (47.9%), and district and community nurses (46.3%).
3.6. Over the last decade our annual Employment Survey shows that there has been a significant rise in the numbers of nursing staff feeling under pressure. The proportion of respondents agreeing with the statement ‘I feel under too much pressure at work’, has risen from 51% in 2009 to 63% in 2019. The findings look at the cumulative impact of workloads and work pressure on an individual’s work-life balance, with just two in five (39%) agreeing that they feel able to balance their work and home lives – falling from 62% in 2009.
3.7. As our figures show, working conditions and the workplace have been a significant cause of stress and burnout for nursing staff for some time. Unsafe staffing levels and working conditions, poor management and bullying are all factors which are prevalent in the health and care system and have had a negative impact on nursing staff.
3.8. Similarly, in October 2019, the NMC surveyed nurses and midwives who left the register between November 2018 and June 2019 - 26% of those leaving the register cited “too much pressure” (including stress, poor mental health) as one of their top three reasons for leaving, and “too much pressure” was the second most common reason for leaving the register, after retirement.
4.1. During the pandemic the RCN carried out a survey of members examining their experiences of the pandemic, which returned over 42,000 respondents working across all settings, at all stages of their careers and in all nations of the UK. The results of the survey are published in the Building a Better Future for Nursing series of reports providing a snapshot of the impact of the pandemic on nursing staff.
4.2. Working during the pandemic is a stressful experience for nursing staff. Fear over health and safety, stress levels and patient complexity have all increased, at the same time as staffing levels and the ability to take breaks have worsened. Over half (56%) of our members who responded say that staff morale is worse than before the pandemic.
4.3. A third of respondents reported that they were working more hours than before the pandemic, on top of the already high levels of nursing staff who reported working additional hours before the pandemic. In addition to this, three quarters of nursing staff told us their stress levels were higher than before than pandemic. These stress levels were cited as a major reason for considering leaving the profession.
4.4. In the same survey, 88% of participants said they are passionate about the nursing profession. However, 91% are concerned about the wellbeing of colleagues. 58% of respondents reported that they were concerned about their own physical health and 52% worried about their own mental health. This shows that further support within the workplace is needed to help protect the health and wellbeing of our nursing workforce.
4.5. In addition, we have seen a dramatic increase in calls to our member helpline relating to stress, burnout and mental health. We analysed the ‘tagging’ for calls made to our helpline, looking at calls tagged with stress(ed), anxiety, anxious, tried, PTSD, tearful, exhausted, overwhelmed and drained. Since 2017 there has been a steady, small increase in the number of calls of this nature. However, for the period from March to mid-August 2020 there was a 27% rise in these types of calls compared with the same period last year.
4.6. Our Counselling Service also found that ‘health’ was among the top 5 workplace issues presenting for the first time. In the period between March and June 2020, our counselling service also found that 23% of members who accessed the service reported suicidal ideation (compared with 16% of members accessing our counselling service in the same period last year). Similarly, 15% of members accessing counselling self-assessed their psychological distress at severe levels of distress, compared to 9% of the same period the previous year.
4.7. However, the impact of the pandemic has been different for different sectors, and for different groups of nursing staff. While 39% of nursing staff employed in NHS settings said that working conditions had deteriorated during the pandemic, the equivalent figure in social care was 49%.
4.8. Nursing staff working in social care settings were also more likely to report that that their ability to take breaks had worsened (35%), and that service user expectation has increased (52%), putting further pressure on nursing staff working in those settings.
4.9. Further issues exist in the independent sector where employers may not offer full sick pay to their nursing staff, instead forcing them to take statutory sick pay. This is not acceptable, and the RCN calls on all employers to make full sick pay available. This is borne out in our survey, which showed that 48% of nursing staff working in independent/private social care settings stated that improved sick leave/pay would make them feel more valued compared to 7% working for NHS Trusts.
4.10. The possibility of receiving statutory sick pay for COVID related absences clearly creates the risk of acute financial distress for nursing staff who would be receiving a very significant pay cut while on sick leave.
4.11. There are also more general issues around financial distress for nursing staff, which undoubtedly contributes to wider issues of stress, burnout and mental illness. However, these effects are not evenly distributed among nursing staff, with nearly three quarters (71%) of BAME respondents worried about their financial circumstances, compared with over two fifths of white respondents (44% of white respondents).
4.12. At the end of 2019, 27% of respondents were considering leaving the profession, and this has increased to 35% (around 14,000 nursing staff) expecting they will be considering leaving by the end of 2020.
4.13. Of those considering leaving, 61% of members say it is due to pay, and 44% say that the way nursing staff have been treated during the pandemic is also a factor. Other reasons given include low staffing levels and lack of management support. BAME members who responded are more likely than white respondents to cite bullying and harassment, unsafe working environments and lack of opportunities as reasons for considering leaving nursing.
5.1. Any vacant post, in any setting, threatens the quality of care patients receive and compromises their safety. As the population continues to grow and our workforce ages, without sufficient and meaningful efforts to grow the nursing workforce, and retention measures, the current staffing shortage is only set to increase, and therefore further risks the safety of patients and public health.
5.2. In England, the recent publication of the NHS People Plan included some welcome announcements around issues such as flexible working. However, in its current form the Plan does not go far enough to address issues around culture and bullying and crucially, it does not sufficiently address the gaps in the workforce and resulting issues around stress, mental illness and burnout experienced by nursing staff. As we have consistently argued, only accountability in law will tackle the siloed decisions that take place on workforce planning, finance, and service design.
5.3. The Government in England must take rapid action to deliver a fully-funded and modelled workforce strategy which can deliver and support the NHS Long Term Plan and meet demand. The delay in delivering this is particularly concerning given staff shortages and the role that nursing staff continue to play in the pandemic.
Fair pay for nursing staff
5.4. Nursing is a safety critical profession, one that is vital to our country’s wellbeing and to our health and care system. It is a highly skilled, responsible profession which deserves fair pay that reflects the complexity and impact of its contribution. The pandemic has shone a spotlight on the critical role undertaken by nursing staff across the UK on a daily basis.
5.5. In August, the RCN launched the Fair Pay For Nursing campaign, aiming to secure a 12.5% pay increase for all nursing staff covered by Agenda for Change terms, as part of a one-year deal that applies equally to all pay bands. This must be fully funded and not come from existing budgets.
5.6. In our survey nursing staff told us that they did not feel valued by the Government, with just 18% of respondents stating that they felt valued by the Government in their part of the UK. Crucially nearly three quarters (73%) said improved pay would make them feel more valued, while half (50%) said better staffing levels would make them feel more valued.
5.7. Nearly half (49%) of respondents are worried about their financial circumstances. However, 71% of BAME respondents have this concern, compared to 44% of white respondents. It is highly likely that these concerns about their financial situation compound other stresses that nursing staff are experiencing.
5.8. Among nursing staff, in our 2019 Employment Survey, 55% of nursing staff were the primary earner in their household, and 27% were the sole earner. Almost a quarter (23%) told us that they have another job in addition to their main job. Of these, around half (55%) undertake bank nursing, a quarter work through an agency (23%) and 17% work additional hours in their main job.
5.9. Of those nursing staff who take an additional job and work additional hours, 40% work an additional 5-10 hours and 39% work more than 10 additional hours. The overwhelming reason for working additional hours over and above a main job role is given as the need to provide additional income (86%).
5.10. The lack of adequate pay for nursing staff therefore has a damaging impact on staff recruitment and retention, as well as impacting on the mental health of nursing staff, causing them additional stresses and leading them to work additional hours.
5.11. Nursing staff who have worked through the pandemic have faced intense psychological pressures and witnessed traumatising situations. Risk assessments must be carried out and acted on to ensure the safety of staff.
5.12. As part of the reopening of services we are calling for the proper management and support for the health and wellbeing of all nursing staff. This includes enabling staff to take breaks at work, their annual leave, and by reviewing and controlling working patterns to prevent long shifts or excess hours being worked.
5.13. All employers must make available and fund timely access to confidential counselling and psychological support for all staff. Staff must be able to self-refer to these services. It is also essential that any barriers that may prevent nursing staff from accessing these services are addressed by government and employers.
5.14. It is vital that all health care staff across the UK have access to quality counselling and psychological support services during and after this critical time. The RCN expects all employers to ensure that adequate, easy to access and timely mental health support is in place.
5.15. Long-term, government, together with employers, must address the issue of inconsistent access to supervision and support amongst the nursing workforce. Supervision provides a safe environment for reflection on practice as well as exploring emotional reactions to the work.
5.16. It is essential that this access to psychological support and counselling is made available to staff working in social care and other independent settings. Employers in the independent sector often lack the same infrastructure as the NHS in terms of occupational health provision and lack the funding to implement the same initiatives to tackle burnout and improve staff resilience.
For further information please contact Euan Sinclair Elliot, RCN Public Affairs Adviser:
 Professor Gail Kinman, Dr Kevin Teoh and Professor Anne Harriss (2020), The mental health and wellbeing of nurses and midwives in the United Kingdom, https://www.som.org.uk/sites/som.org.uk/files/The_Mental_Health_and_Wellbeing_of_Nurses_and_Midwives_in_the_United_Kingdom.pdf
 Garcia, Abreu, Ramos, Castro, Smiderle, Santos and Bezerra, 2019. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina, [online] 55(9), p.553. Available at: <http://dx.doi.org/10.3390/medicina55090553>.
 Skills for Care (2019), The state of the adult social care sector and workforce in England, https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/State-of-Report-2019.pdf
 Royal College Of Nursing (2019) Employment Survey 2019 Available at https://www.rcn.org.uk/professional-development/publications/pub-007927
 Society of Occupational Medicine & RCN Foundation (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
 Royal College of Nursing Employment Survey 2009 https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/publications/2009/october/pub-003545.pdf
 Nursing and Midwifery Council (2020) Leavers’ survey 2019 Available at https://www.nmc.org.uk/globalassets/sitedocuments/nmc-register/march-2020/nmc-leavers-survey-2019.pdf
 Royal College of Nursing (2020), Building a better future for nursing: RCN members have their say, https://www.rcn.org.uk/professional-development/publications/rcn-builiding-a-better-future-covid-pub-009366
 Royal College of Nursing (2020) Staffing for safe and effective care in the UK 2019 report: reviewing the progress of health and care systems against our principles