The NHS is run on people like us. But at what cost?
Newly qualified midwife
There are many unheard and under-acknowledged voices and perspectives in the health and social care workforce, and they usually belong to those in the most junior, poorest-paid and precarious roles. All these voices deserve more attention than they get, but those of newly qualified and registered nurses and midwives are especially important given the current retention crisis in both professions.
Since spring 2023, we have been working with 22 newly qualified - newly registered if they trained internationally – nurses and midwives on a project called Follow Your Compassion. A documentary record of the everyday working lives of these nurses and midwives across a variety of settings across the UK health and care system, the project is a companion piece to The Courage of Compassion (2020), a report by The King’s Fund and RCN Foundation which described the core workplace needs of nurses and midwives, and what must be done to meet them.
Each participating nurse and midwife kept a journal over several shifts, and described the sights, sounds, smells and rhythm of their day or night, as well as their thoughts and feelings about the work and workplace. Using words, audio, photography and video, the group powerfully brought to life experiences of and perspectives on the health and care system that are rarely heard. All parts of the UK are represented in the project, as are all fields of midwifery and nursing. The only exception to this is nursing in social care. We were not able, despite our best efforts, to recruit anyone in this sector.
When you start out it can feel like ‘trial by fire’. It’s like an initiation not an induction.
Newly qualified nurse
Perhaps unsurprisingly, while we did hear some positive stories of training, management, and culture, the overwhelming experience of participants at work was of feeling unprepared, anxious, silenced and exhausted. Participants shared troubling experiences of their working life in psychologically unsafe teams and toxic departmental cultures, a chronic and pervasive fear of making a career-ending clinical mistake, uncompassionate management and everyday incivility.
The work nurses and midwives do is high stakes, with significant and disproportionate responsibility foisted on them almost immediately after qualifying. The pay and conditions, relative to these stakes, are poor. Life, death and human suffering are everyday encounters, and the work of caregiving – even without the workplace context described – is emotionally demanding. It’s also important to note the demographic inequity baked into the newly qualified nursing and midwifery workforce, since most are young women. And for those who trained internationally, a whole new way of life and experience of discrimination must be navigated, alongside a new culture and system of care.
The reason for leaving my first place of work was that I was not being supported… It is hard to put the situation down in writing because of the fear that the management may see it as an attack on them.
Newly qualified nurse
What do these experiences have to teach us about the state of the nursing and midwifery workforce, and the future of these professions? When we spoke with managers and leaders of nurses and midwives to explore this, one thing became very clear – none of this is new. Most described similar experiences and feelings in their own memories of qualifying, stretching back more than three decades in some cases. And many continue to experience feelings of anxiety, fear and overwhelm even in more senior roles; squeezed as they are by the priorities of strategic leaders and the realities and needs of those working directly with patients. A few managers even suggested these experiences and feelings are inevitable, perhaps even necessary, to help ‘weed out’ practitioners less well suited to the demanding reality of the professions, and that the sensitivities of those complaining today are indicative of a generational lack of resilience.
But newly qualified nurses and midwives experience these attitudes, cultures and behaviours, not just from managers, but also from peers only a few months further into their working life. And it is this cultural transmission of norms, attitudes and behaviours that is most concerning. Because while we heard managers and leaders defend the various support structures and processes in place for newly qualified staff inside their organisations, it became clear to us that without both the right cultural conditions and structural arrangements, the experience of newly qualified and registered staff, (and therefore the issues around retention) won’t improve. Put another way, there is a symbiotic relationship between team culture and formal support offers like preceptorship; neither will make a difference improving workplace experiences without the other. And yet too often the cultural aspect of this relationship is left unattended.
The adverse implications of working cultures characterised by fear, anxiety and incivility on staff wellbeing are obvious. But we also heard that the actual practice of both nursing and midwifery is being reduced to a series of transactional tasks devoid of the caregiving purpose that keeps many people in these professions, often despite the wider workplace challenges. The world of work is changing, and younger members of the workforce today may have different tolerances than in the past for terms and conditions that can be easily bettered elsewhere in the labour market. All this is in the context of a health and social care system filled with various post-pandemic legacies, industrial action, and a spiraling cost-of-living crisis that hits newly qualified staff hardest. There is a perfect workforce storm in nursing and midwifery.
Follow Your Compassion reveals the gap between the ambition for compassionate, inclusive leadership and the real-world experience of new nurses and midwives is not so much a gap as a chasm. Leaders must now actively listen and attend to the experiences of newly qualified and registered staff, because their distress or success will define the future of both professions. But to do this effectively, leaders must be mindful not to use their authority and own early career experience to delegitimise these voices. Continuing to create a false dichotomy between the needs of a service and the needs of staff risks disaster; the needs of newly qualified and registered staff are the needs of any service that has an ambition to provide high-quality care.