Written evidence submitted by Bliss (WBR0094)

Bliss evidence to the House of Commons Health and Social Care Committee

Inquiry: Workforce burnout and resilience in the NHS and social care

About Bliss

Bliss exists to give every baby born premature or sick in the UK the best chance of survival and quality of life. We champion their right to receive the best care by supporting families, campaigning for change and supporting professionals, and enabling life-changing research.

Introduction

Around 300 babies will be admitted to neonatal care every day in the UK. Around 60 per cent of these babies are born at term (37 weeks or more) and the other 40 per cent will require care because they were born premature. Many babies will spend weeks or months in neonatal care before they are ready to go home. Sadly, some babies will never go home at all.[1]

The delivery of safe, high quality care is dependent on neonatal units being staffed and resourced appropriately. It is particularly important that the neonatal workforce is sufficient – in both numbers and skill mix – to ensure babies have the best possible chance of survival and quality of life, and for ensuring parents are supported to be partners in their baby’s care.

Demand for neonatal services continues to grow with increasingly complex births becoming more common, more babies being cared for at earlier gestations and initiatives to reduce stillbirths aligning with an increase in neonatal admissions and premature births.[2] However, there are acute pressures and challenges facing the neonatal workforce today and this is set to get worse if urgent action is not taken.

The impact of working in an understaffed service on staff wellbeing is acute, with more than half of respondents to a Bliss survey (conducted in 2019) saying their mental health had deteriorated as a result of their work on the neonatal unit over the last 12 months. The vast majority name understaffing and unmanageable workloads as key reasons for this.

Staffing shortages in neonatal care

Numerous sources provide evidence that staffing levels on neonatal units are not adequate. Nurse staffing levels are routinely below national recommendations (both in quantity and skill level). 2018 data shows that 64 per cent of shifts were numerically staffed according to national guidelines and just 44 per cent of shifts had sufficient staff qualified in specialty. Only 21 of 53 NICUs had half or more of their shifts with sufficient staff qualified in speciality[3]. L Patterson et al found that there were 2263 WTE neonatal nurse vacancies across all units in England, vacancy rates vary but in one area the vacancy rate was as high as 27.2 per cent. [4] In addition, around 15 to 18 per cent of medical posts in neonatal care (excluding consultant level) are unfilled and 6 per cent of consultant posts also go unfilled.[5]

L Patterson et al also found that the most common reason for vacancies in the neonatal nurse workforce at the time of their research was retirement (21 per cent). [6] The age profile of those currently in the profession is of concern, with one third of neonatal nursing staff aged fifty or older. At the other end of the age spectrum, there are also high maternity leave rates (which are not seen in the ‘vacancy’ rates but leave gaps in the workforce nonetheless) as the neonatal workforce is largely female.

The future sustainability of the medical workforce is also concerning, with a 28 per cent fall in national applications to train in paediatrics in 2017, where neonatal specialist registrars are drawn from and sub-specialty training posts frequently go unfilled in some areas of the country.[7]

Shortages in both the neonatal medical and nursing workforce have a clear impact on the real and perceived safety of the service. A recent Royal College of Paediatric and Child Health and Getting It Right First Time programme snapshot survey found that while 89 per cent of both medical and nursing staff felt the service was safe all or most of the time on a week day shift, this fell to 83 per cent (medical) and 85 per cent (nursing) at the weekend when staffing levels are typically lower. Administrative staff are also important to the safe working of the service, but just 52 per cent of medical staff working a weekend shift felt that there was sufficient administrative staff to manage the service safely. [8]

The impact on mental health and well-being of staff

In the context of staff shortages in an ever-growing, high pressure service, support for staff mental health is essential to ensure the wellbeing of staff, to reduce sickness absence and to reduce the numbers leaving the service.

In 2019, Bliss surveyed 719 neonatal staff and found that mental health and wellbeing was seriously affected by working within the neonatal environment. Over half (55 per cent) of respondents said their mental health and well-being had deteriorated over the last 12 months due to the impact of the neonatal environment.

More than three in four respondents reported an inability to switch off from work, 70 per cent reported high levels of stress and a further 70 per cent said they frequently felt run down or ill. Around half of respondents said they experienced compassion fatigue and another 50 per cent experienced anxiety. 49 per cent said they experienced low mood. Many respondents also reported they experienced more severe symptoms including flashbacks and intrusive thoughts (24 per cent), panic attacks (12 per cent) and suicidal thoughts and feelings (7 per cent).

The impact of these effects on the mental health and wellbeing of staff were clear, with over half (55 per cent) of respondents reporting that they had taken time off work over the last 12 months because of the impact of the neonatal environment on their mental health and wellbeing. Almost half, (48 per cent) of respondents said they were, or had previously, considered leaving either their workplace, or neonatal services as a whole due to the impact of the neonatal environment on their mental health and well-being.

The key factors reported by our respondents, that had contributed to reduced mental health and well-being in their workplace were understaffing (identified by 87 per cent of respondents), unmanageable workloads (68 per cent) and the under resourcing of the neonatal service (56 per cent). Other factors also identified were dealing with bereavements in the workplace (48 per cent), witnessing traumatic events at work (44 per cent) and poor working relationships or culture (40 per cent).

Mental health support at work

Although there is a clear need for mental health support for staff working in neonatal services, only 27 per cent of respondents to Bliss’ 2019 survey said there was a trained mental health professional working within their neonatal service who could provide support to neonatal staff. 98 per cent of professionals who did not have access to a trained mental health professional within their service felt this provision would be beneficial for at least some staff in their workplace.

Respondents working in a setting with no mental health and wellbeing support were more likely to say their mental health had deteriorated and less likely to say it had stayed the same.

Staff mental health and wellbeing in the COVID-19 context

During the COVID-19 pandemic, parental access to babies in neonatal care has changed dramatically. Neonatal units typically allow parents to be present with their baby 24 hours a day and encourage full participation in care giving, which evidence shows leads to improved outcomes for babies and parents. But in the current context, units have restricted this access, often to allow only one parent at a time, or one or both parents restricted to seeing their baby for a certain number of hours per day (sometimes as little as 2 maximum).

While the need for parents to be on the unit and involved in their baby’s care is clear from the perspective of improving outcomes for babies and their parents, it is also important to staff. When parents are able to care for their baby on the unit, this takes pressure off neonatal nursing staff to provide basic care tasks that could be undertaken by parents. During the pandemic, restrictions on parent access means that parents are not able to take on these responsibilities as often as they would in normal times, putting further pressure on already stretched staff time.

Bliss has spoken to neonatal staff about the impact of access restrictions and have heard from staff who feel that enforcing these rules “has strained relationships” between staff and parents, “parents are often upset” and it is “hard for the staff to enforce” restrictions. This will impact, not just on the mental health of parents, but on staff well-being too.

In the current context, parents are often only able to attend the unit alone, without the support of their partner or wider family. Staff have told us that because of this “Parents have often required a lot more support from midwives/neonatal staff, which when the nursing team are extremely busy can impact on the parent-nurse relationship as they feel unsupported and stressed.” As a result of restrictions imposed during the pandemic, staff take on the responsibility for emotional support that is usually provided by the parent’s family.

Additionally, the pressure COVID-19 has placed on staff across the Health Service has been widely acknowledged. Many staff, including those working in neonatal settings, were redeployed to different specialties, or were returned to more acute clinical settings from the community or non-clinical roles. Many staff have also experienced grieving for colleagues and friends while continuing to work, as well as adjusting to the wider societal changes as a result of COVID-19. It is likely these incredibly difficult circumstances will contribute significantly to fatigue, burnout rates and negative consequences for staff well-being and mental health. Indeed, a survey of more than 3,500 nurses by the Nursing Times as part of their COVID: Are you OK? Campaign found 90 per cent of respondents said they were ‘’a lot’’ or ‘’a little’’ more anxious than before the outbreak and two thirds noted their work had changed either significantly or completely as a result of the pandemic.[9]

Action is needed

Caring for babies born premature or sick in high-pressure environments is practically and emotionally challenging – and Bliss’ 2019 survey findings show that staff are being pushed to breaking point when they work in environments which are over-stretched, under-resourced and lacking in support.

Evidence is clear that the smallest and sickest babies have the best outcomes when they are cared for by services which have optimal staffing levels. But the nursing and medical shortfall is affecting neonatal services across the UK. If even a fraction of the professionals who are considering leaving the profession do decide they have no option but to leave neonatal services for good, it will be the most vulnerable babies who will feel their loss the most.

We were glad to see that the NHS People Plan 2020/21 acknowledged that the pandemic has had a significant impact on the mental and psychological health of NHS staff, but this was an epidemic in neonatal services long before COVID-19. Governments and Health Services across the UK must now fulfil the commitment made in the NHS People Plan to provide psychological support to staff by investing in comprehensive support for neonatal staff as a matter of urgency so that this can realistically be achieved.

November 2020