Written evidence submitted by UNISON
- UNISON is the UK’s largest union, with more than 1.3 million members providing public services – in the NHS, local government, education, the police service and energy. They are employed in the public, private and voluntary sectors. UNISON is the largest union in the NHS.
- Thousands of UNISON members in a variety of sectors are on the frontline in dealing with the response to the Covid-19 pandemic. Wherever possible the union is working alongside governments, the NHS, councils and others to play a part in containing the spread of the infection and treating those suffering its effects.
- Prompted by the NAO report and the inquiry terms of reference, this submission covers the main problems affecting the nursing workforce – in terms of education and training and safe staffing; the impact that the Covid-19 pandemic has had on the nursing workforce; a series of policy recommendations that would help tackle these issues; and a number of suggested questions which the inquiry could usefully seek answers to. Much of this submission consists of survey evidence or direct testimony from UNISON members working on the frontline, both before and during the pandemic.
Long-term problems: education and training
- Attracting enough new entrants into nursing is a significant challenge. While demand for nursing and care services has grown rapidly over the past five years, the numbers applying to study nursing have dropped. Despite recent improvements, the numbers applying to study nursing degrees have still not recovered to the 2016 level, before the NHS bursary was scrapped and tuition fees introduced for nursing students in England. Many prospective healthcare professionals have been deterred from studying at university due to the prospect of debt. This is also a major reason why the NHS nursing workforce in England entered the Covid-19 crisis with almost 40,000 unfilled posts.
- Nursing, midwifery and allied healthcare students have made a significant contribution to the health of our country in the response to the pandemic. Many have formally entered the workforce ahead of schedule to work on the frontline, while others undertook paid placements to provide care in health and care settings. Many have also had their studies interrupted. However, at the same time as working on the frontline of this health emergency, healthcare students in England have continued to pay tuition fees for their education despite experiencing severe disruption to it.
- The government recently announced that maintenance grants will be reintroduced for healthcare students in England from September 2020, but these are only half of what students in Scotland are set to receive and tuition fees will still have to be paid. In addition, those students who started their courses in Spring will not be able to receive the grants until the beginning of their next academic year in Spring 2021. The continuation of tuition fees in England also affects healthcare students from other parts of the UK, many of whom choose to study in England.
- Ensuring quality supervision and support for nurses in training is another major challenge. Cuts in teaching grants to universities coupled with disruption to courses and normal methods of teaching because of Covid-19 are significant issues for the sector to deal with. The pandemic also means there will be many students in training who have lost placement hours which they need to make up.
- Feedback from members of UNISON’s student nurses’ network confirms the negative impact of such issues. They report that workforce shortages can create a toxic learning environment for student nurses, and that registered nurses are often too stretched to offer quality supervision and support, making it harder for students to complete their studies and develop professionally. They also point out that nursing workforce shortages can contribute to bullying and harassment in their placement environments, as staff supervising them are too often left exhausted by their own workloads. Nursing students report having to take on second jobs to make ends meet on top of their demanding degree courses. This leads many to suffer from burn-out in their third years and drop out or require an extended break before they feel able to join the full NMC register. The overwhelming feeling is that the nursing role is undervalued and under-recognised; the lack of investment in improving nurses’ pay has undermined the status of the profession, which puts many off entering nursing education in the first place.
- In the words of Joy O’Gorman, a second year nursing student and UNISON national student nurse lead:
“A nursing degree is tough; it takes a will of steel and passion to progress to the finish line. Most of us that do manage to become registered nurses, qualify burnt out. We begin our working lives exhausted from trying to make ends meet, undertaking full time placements and meeting academic requirements over a gruelling three years. Almost £60K in debt is a heavy burden to add to this commitment.’’
Long-term problems: safe staffing
- At the start of March 2020, just prior to the lockdown, UNISON hosted a Safe Staffing Forum to hear from more than 60 nurses, midwives, healthcare assistants, students and allied health professionals about the issue of workforce shortages and safe staffing in their services. The key survey evidence gained from the event is outlined below.
- When asked, in relation to their most recent shift in work, whether they had enough staff to provide safe, dignified care nearly half (47%) disagreed, and more than half (51%) disagreed that the skill mix and experience of their team was sufficient to provide safe, dignified care. Two-thirds (65%) disagreed that staffing levels were sufficient to supervise and support students and other learners, while the same percentage disagreed that staffing levels provided them with enough time to meet their continuing professional development (CPD) requirements. Worryingly, more than half (53%) felt that the wellbeing of their patients was affected by unsafe staffing levels and 56% agreed that the safety of their patients was compromised by unsafe staffing levels.
- In terms of the impact on staff themselves, two-thirds (65%) did not believe that staffing levels were sufficient to allow them to take adequate breaks and leave on time, with a similar proportion (63%) reporting that staffing levels contributed to anxiety and high amounts of stress for them. Anecdotally, attendees reported that the health implications they faced included dehydration, poor diet, anxiety, stress, guilt, low morale and negative effects on their family relationships.
- The event also took soundings from groups of staff working in different parts of the sector. In acute settings, a key theme to emerge was the poor skill mix participants felt often existed in their areas, affecting the safety of their patients. Nurses and others reported the inflexibility of their organisations and how difficult it was to secure help and additional staffing.
- In mental health it was reported that workforce shortages and a lack of experienced staff led to more violence and a greater use of physical restraint in their services. It also made it much harder for staff to continue their professional development and to support students wishing to develop into mental health nurses in the future. This is particularly concerning given the widely recognised need for greater capacity in mental health services, which is likely to be compounded further by the Covid-19 pandemic.
- Staff from community settings reported an ongoing decline in the numbers of community nurses at the same time as demand for their services continues to rise. This resulted in less time available to deliver care, making readmission to hospital more likely for many patients. (The number of nurses registered with specialist community and public health qualifications has fallen every year since 2016.)
- These are not new issues but part of an ongoing trend. Each year UNISON carries out a snapshot survey of nursing members to gauge their experience at work on a given day. The 2019 edition of the survey revealed that poor staffing is seriously affecting the quality and safety of patient care: half (49%) of respondents said there were not enough staff on their shift to deliver safe, dignified and compassionate care; 41% of staff in acute areas reported that quality of care was compromised by poor staffing; and 38% of respondents said they could not provide the right level of supervision and learning opportunities. The survey also showed that unsafe staffing and lack of support is a serious problem for staff wellbeing: 47% reported being unable to take their allocated breaks and one in six could not take any break at all on their shift; 38% did unpaid work over their scheduled hours; 36% said they could not deliver safe care; and one in five students survey reported very high stress levels, with 68% of all respondents reporting significant stress.
- Such figures reveal a deeply dispiriting picture for the staff working in under-staffed wards or departments, but crucially a lack of safe staffing also has a real impact on patients. Recent research evidence shows that lower rates of registered nurse staffing and higher rates of admissions per registered nurse are associated with an increased risk of death for a patient during a hospital admission. And low registered nurse staffing levels are also associated with poorer staff/patient interaction and patient satisfaction with their care.
The impact of Covid-19 on the nursing workforce
- Nursing workforce shortages meant that the NHS and social care were badly unprepared to cope with the pressures of the pandemic. The NMC had to introduce emergency standards allowing nursing and midwifery students to work as paid NHS employees to enable this gap to be filled. A temporary register was introduced without the normal safeguards and processes to allow retired nurses and nurses from overseas who had yet to complete the full registration process to work and contribute.
- Critical care nursing was recognised as an area of shortage prior to the pandemic and this workforce was severely stretched by the huge numbers of patients requiring intensive care with the virus during the peak of the pandemic. Normal standards and ratios of patients to nurse intended to protect standards of care had to be relaxed to allow increased numbers of patients to be cared for, which inevitably increases the potential for mistakes and patient harm.
- Almost half of the recent increase in nurses and midwives on the NMC register is as a result of international recruitment of nurses from outside the EU, particularly from the Philippines and India. Unfortunately, since these figures were collated this route has been significantly disrupted by Coronavirus and the travel restrictions that have been in place since April.
- UNISON organisers and workplace reps reporting that nurses, midwives and other health professionals are experiencing significant stress, anxiety and exhaustion from their work throughout the pandemic. There is a real risk of a significant longer-term loss to the nursing workforce due to burnout if excessive workloads are not addressed.
- Based on the above, UNISON recommends the following actions be taken to tackle the major issues relating to the NHS nursing workforce:
- tuition fees for healthcare students in England should be scrapped and living maintenance grants introduced that reflect actual student need;
- safe staffing legislation should be introduced in England, building on the experience of legislation in Cymru / Wales, to boost investment in nursing and improve work environments;
- extra funding should be provided for emotional and mental health support for nurses (and other health and care staff) as the NHS seeks to recover from Covid-19;
- CPD budgets must be protected for nurses and other healthcare staff, with better protected time for supporting learners, students and junior staff;
- the vital role performed for our NHS by nurses from overseas both before and during the pandemic needs to be recognised – ministers must keep their promise to drop the immigration health surcharge and provide refunds for fees already incurred; and
- building on the huge public support for the NHS during the pandemic, there needs to be an early – and meaningful – pay rise for nurses (along with other healthcare staff).
Suggested questions for the inquiry to probe
- There are also a number of questions which UNISON suggests Committee members pose to politicians and officials giving evidence as part of this inquiry:
- What steps will be taken to tackle the issue of chronic safe staffing which is affecting standards of care and nurses’ health and wellbeing, leading many to consider leaving the profession?
- Given the drastic nature of the emergency measures which had to be taken to enlarge the nursing workforce to meet the challenges of the pandemic, what steps will be taken to strengthen the nursing workforce to ensure that such steps do not need to be repeated in future?
- Nursing, midwifery and other healthcare students in England continued to pay tuition fees despite being asked to join the workforce to assist in the response to the pandemic – how can this be considered fair and what further steps are being explored to compensate them?
- Given the widely acknowledged stress and pressure placed on the nursing workforce by the pandemic, what steps are being taken to invest in the workforce and ensure there is a not a huge loss to the profession in the future?
 Griffiths P, Maruotti A, et al, “Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study”, BMJ Quality & Safety 2019;28:609-617,
 Bridges J, Griffiths P, Oliver E, et al, “Hospital nurse staffing and staff–patient interactions: an observational study”, BMJ Quality & Safety 2019;28:706-713,