The courage of compassion: Supporting nurses and midwives to deliver high-quality care

This content relates to the following topics:

Part of Compassionate and inclusive leadership

Overview

  • The Covid-19 pandemic has put the UK health and care workforce under unprecedented pressure. The workforce had been struggling to cope even before the pandemic took hold. Staff stress, absenteeism, turnover and intentions to quit had reached alarmingly high levels in 2019, with large numbers of nurse and midwife vacancies across the health and care system. And then the pandemic struck.  

  • The impact of the pandemic on the nursing and midwifery workforce has been unprecedented and will be felt for a long time to come. The crisis has also laid bare and exacerbated longstanding problems faced by nurses and midwives, including inequalities, inadequate working conditions and chronic excessive work pressures.  

  • The health and wellbeing of nurses and midwives are essential to the quality of care they can provide for people and communities, affecting their compassion, professionalism and effectiveness. 

  • This review investigated how to transform nurses’ and midwives’ workplaces so that they can thrive and flourish and are better able to provide the compassionate, high-quality care that they wish to offer. 

  • Nurse and midwives have three core work needs that must be met to ensure wellbeing and motivation at work, and to minimise workplace stress: autonomy, belonging and contribution. 

  • This report sets out eight key recommendations designed to meet these three core work needs. These recommendations focus on: authority, empowerment and influence; justice and fairness; work conditions and working schedules; teamworking; culture and leadership; workload; management and supervision; and learning, education and development.

Context

Even before the outbreak of the Covid-19 pandemic, the health and social care workforce across the United Kingdom was struggling to cope. One of the greatest challenges is in nursing, with 43,590 NHS nurse vacancies in England; 3,607 nurse and midwife posts vacant in Scotland; 2,488 nursing, health care assistant and nursing assistant vacancies across health and social care in Northern Ireland; and an estimated 1,651 nursing vacancies in the Welsh NHS.

The King’s Fund has identified a large and growing gap between capacity and demand in district nursing services, with staff reporting feeling ‘broken’, ‘exhausted’ and ‘on their knees’. There has been a 35 per cent reduction in health visitors in England’s NHS between 2015 and 2020 and a 38 per cent decrease in learning disability nursing numbers between September 2010 and September 2019.

The adult social care sector has also been under huge pressure and faces many of the same issues as the NHS. In all four UK countries there are high levels of vacancies for nursing in social care. In adult social care in England, the registered nurse vacancy rate before the Covid-19 pandemic was 12 per cent, and registered nurse was one of the only job roles in adult social care to see a significant decrease (30 per cent) since 2012/13.

Staff stress, absenteeism, presenteeism, turnover and intentions to quit had reached alarming levels among nurses and midwives in late 2019. The UK-wide Royal College of Nursing (RCN) employment survey 2019 suggested that nearly a quarter of nurses and midwives were looking for a job outside the NHS. In the 2019 English NHS national Staff Survey, 44 per cent of nurses and midwives indicated that they had been unwell as a result of work-related stress in the previous 12 months, the highest percentage reporting this in the past five years. More than half reported attending work in the past three months despite not feeling well enough to perform their duties. And then the Covid-19 pandemic struck.

The health and wellbeing of nurses and midwives are essential to the quality of care they can provide for people and communities, affecting their compassion, professionalism and effectiveness. Ensuring that working conditions across all settings – in primary, secondary, mental health, community and social care – are supporting nurses and midwives in their work is fundamental to ensuring the best outcomes for people who need health and care services. This report focuses on their work life experience and what needs to be done to address the problems they face.

It requires the courage of compassionate leadership from all leaders, at every level of our health and care systems across the four UK countries, to engage with and successfully address the challenges that nursing and midwifery services face. Doing so is critical to our ability to care for the health and wellbeing of everyone across the United Kingdom.

Our research

Our research explored the causes and consequences of poor mental health and wellbeing among nurses and midwives, and sought to identify solutions to these issues and examples of good practice. The scope of the review covered all nursing and midwifery staff and students, including health care assistants and nursing associates, across the UK. 

The review team gathered evidence through a literature review, secondary analysis of quantitative data, focus groups with nursing and midwifery staff and semi-structured interviews with stakeholders from across the four UK countries. The interviews were conducted with nursing and midwifery staff at a range of levels of seniority, representative bodies and royal colleges, government departments in each UK country, regulators and improvement bodies, and workforce leaders at organisational, regional and national levels. 

The report focuses on how to develop good work environments for nurses and midwives by changing the workplace factors that affect their wellbeing and effectiveness at work, rather than focusing on ways to help them cope with negative working environments or providing treatment when they become unwell. Efforts must be focused on changing the factors that cause stress rather than only dealing with symptoms. 

This report was commissioned by the RCN Foundation. The views in this report are those of the authors and all conclusions are the authors’ own.

ABC of nurses’ and midwives’ core work needs

To ensure wellbeing and motivation at work, and to minimise workplace stress, research evidence suggests that people have three core needs:

  • autonomy – the need to have control over their work lives, and to be able to act consistently with their values  
  • belonging – the need to be connected to, cared for, and caring of others around them at work, and to feel valued, respected and supported 
  • contribution– the need to experience effectiveness in what they do and deliver valued outcomes.

All three must be met for people to flourish and thrive at work. The review identified eight key areas where action is needed to ensure that these three core needs are met for nurses and midwives (see Figure 1, below).

The ABC framework of nurses' and midwives' core needs

Recommendations

The report sets out eight key recommendations, alongside a set of detailed practical steps to be taken to make progress against each. The recommendations are set out in full in Appendix 1 of the report. In the body of the report, we also provide case study examples of organisations that are implementing one or more of the recommendations in effective ways. 

The recommendations set out in the report are addressed to all leaders who influence the workplace experience of nursing and midwifery staff. Regulators, improvement bodies and all partners in health and social care should support organisations to effectively implement each and every recommendation, not just those that seem most expedient or attractive.

Transforming the working lives of nursing and midwifery staff, and thereby the quality and sustainability of the care they provide, requires that we implement an integrated, coherent and comprehensive strategic approach.

Key recommendation 1: Authority, empowerment and influence 

Introduce mechanisms for nursing and midwifery staff to shape the cultures and processes of their organisations and influence decisions about how care is structured and delivered.  

Key recommendation 2: Justice and fairness 

Nurture and sustain just, fair and psychologically safe cultures and ensure equity, proactive and positive approaches to diversity and universal inclusion. 

Key recommendation 3: Work conditions and working schedules   

Introduce minimum standards for facilities and working conditions for nursing and midwifery staff in all health and care organisations.  

Key recommendation 4: Teamworking  

Develop and support effective multidisciplinary teamworking for all nursing and midwifery staff across health and care services.  

Key recommendation 5: Culture and leadership  

Ensure health and care environments have compassionate leadership and nurturing cultures that enable both care and staff support to be high-quality, continually improving and compassionate.   

Key recommendation 6: Workload  

Tackle chronic excessive work demands in nursing and midwifery, which exceed the capacity of nurses and midwives to sustainably lead and deliver safe, high-quality care and which damage their health and wellbeing.   

Key recommendation 7: Management and supervision  

Ensure all nursing and midwifery staff have the effective support, professional reflection, mentorship and supervision needed to thrive in their roles.  

Key recommendation 8: Learning, education and development

Ensure the right systems, frameworks and processes are in place for nurses’ and midwives’ learning, education and development throughout their careers. These must also promote fair and equitable outcomes. 
 

Our call to action

We are calling on all health and social care leaders to lead with compassion by implementing all the recommendations in this report. Organisations with cultures of compassion promote fairness and foster individual, team and organisational wellbeing. Such organisations meet nurses’ and midwives’ fundamental needs for autonomy, for belonging and to be able to make an effective contribution in their work, which in turn improves care quality and efficiency, and better promotes the wellbeing of the patients, people and communities they serve.  

Government, national bodies and all those who influence the workplaces of nurses and midwives must now commit to creating environments that ensure individuals are able to provide care to the standards they aspire to and that their health and wellbeing is prioritised. Their commitment, both during the pandemic and throughout their careers, must be honoured by creating workplaces that support, value and respect the work that they do.

The courage of compassion (free online event)

At this free online event we'll discuss the changes needed to empower nurses and midwives to provide the compassionate, high-quality care that they aspire to through the Covid-19 pandemic and beyond.

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Comments

Donna Berry

Position
Stroke Clinical Nurse Specialist/Ward Manager,
Organisation
Livewell Southwest
Comment date
23 September 2020

This is an excellent document that I have shared with nursing colleagues who are as equally passionate about nursing as I am.
I would be interested in having opportunity to discuss the 12 hour shift issues should this come up in the future and many other of the points raised in this document.

Thank you for your support to nurses working on the frontline

Janet Loker

Position
Retired GP,
Comment date
24 September 2020

In my opinion the length of nursing shifts should be reduced from 12 hours, especially where the work is very intensive. When I was junior doctor the nurses had 3 shifts a day- early, late and nights. I cannot remember why the shifts were changed to 12 hours. They have more days off with 12 our shifts i.e. three shifts a week as opposed to five per week of the shorter shifts. I wonder if the nurses would be willing to change back to shorter shifts to relieve the exhaustion?

Pat Hughes

Position
Midwife / Nurse, Director,
Organisation
MNE
Comment date
25 September 2020

In my experience, the 12 hour shifts have many origins and impacts
Loss of access to hospital accommodation and / or reduced access to affordable communication particularly in cities whereby Midwives and Nurses were forced outwards in order to find affordable accommodation- then resulting in long and expensive commutes and increased needs for childcare.
Access to car parking and or car parking costs were prohibitive in some areas so to have to look at those over 3 shifts a week as opposed to 5 shifts a week was an attractive option
The "add on" unpaid time, coming in early and leaving late over 3 shifts pw as opposed to that happening over 5 shift a week was an attractive option
In an effort to reduce commute time and childcare costs - staff opted for fewer and longer shifts
this had advantages and disadvantages, ? increased continuity of care across the shift but not so across the episode of care as experienced by the patient; an automatic increase in sick leave by 25% so instead of a nurse/ midwife being out on sick leave for one day of 8 hours. s/he was now coded for 8 hours of sick leave. It was hoped that the 12-hour shift, being a more attractive option for midwives and nurses may result in reduced sickness absence. That has not necessarily been found. Indeed 12 hour shifts may in themselves be contributory particularly in short staffed areas where staff may work throughout the shift without any or at least, adequate breaks. As breaktime is generally unpaid time, a shift will often span 13 hours, i.e start at 07.30 hrs- 20.30hrs plus any add on time (coming on duty 15-20 mins early and /or going off duty at 30 mins after shift end or later). So irrespective of any add on time, the 12/13 hour span of duty also raises health and safety concerns for staff in terms of driving home after a shift whereby one may not have had any or an adequate break. I know of 3 cases (2 nurses and 1 midwife) were involved in road traffic accidents on the way home after a shift. in two cases the person died at the scene. In the 3rd case, the nurse died within 24 hours. I think shift times should be more closely monitored and even regulated.

Richard Spicer

Position
Retired,
Organisation
NHS
Comment date
25 September 2020

Recommendation 8 should be more specific. Encourage recruitment as well as retention; reintroduce generous bursaries, increase training places, including a pathway which does not require a degree.

Professor Geor…

Position
Trustee,
Organisation
Healthwatch Oxfordshire
Comment date
25 September 2020

A lovely, highly-skilled, and devoted intensive care nurse inadvertently gave my gravely-ill wife the wrong medication (fortunately without any direct consequences). The nurse had volunteered for extra duties to help support an understaffed unit. She had just completed 11 hours of an additional 12-hour night shift when the error occurred. She was mortified by her mistake, but the blame lay with the system, not with her. She deserved better, and so do all such wonderful, dedicatedl people.

Martin Lincoln

Position
Lead Nurse SRH & HIV,
Organisation
Homerton University Hospital NHS Foundation Trust
Comment date
28 September 2020

I can't thank you enough for this peice of work. It is time to accept past errors in the journey of nursing and embrace the need for change for the better. Enforced working patterns and overburdening workloads have eroded the joy for the art of nursing for some time now.

John Kapp

Position
director,
Organisation
SECTCo (Social Enterprise Complementary Therapy Company
Comment date
09 October 2020

A good report, but misses the point that a million patients per day seek treatments that are evidenced based to work to heal and cure their conditions. The NHS provide this brilliantly for physical problems (such as a broken leg) but not for mental problems (such as a broken heart) for which the only treatment in the GPs power is drugs, which generally do more harm than good.

the solution is medication to meditation, by social prescribing of social (non drug) interventions (such as 10 week exercise, or mindfulness courses) in which the money follows the patient, who gets the course free at the point of use, and the teacher gets paid on receipt of the used social prescription form, signed satisfactory by the patient, as pharmacists are paid for drugs.

Only when the 1.4m staff are treated compassionately like that will people want to work for the NHS., and the vacancies will be filled.

Rebekah Overend

Position
Nurse Educator,
Organisation
Bristol Royal Hospital for Children
Comment date
28 October 2020

Love this article, thank you to all who contributed. Thinking about how to use use the ‘ABC’ as a CPD springboard and how we could facilitate learning about domains for development of nurses across all levels...being able to understand different elements of work is first step to finding collaborative ways to think differently

``Rebekah Overend

Position
Nurse Educator,
Organisation
Brsitol Royal Hospital for Children
Comment date
28 October 2020

Hello Mr Spicer
I agree that more emphasis on recruitment is needed as well as a clear plan for supporting students who cannot supplement incomes in the way other students can due to placements. We need more robust career pathways for Nurses so that the emphasis is on demonstration of the competence of the practitioner and using CPD education purposefully to do so .

However, there are careers in healthcare that are already in place to support those wanting to provide care to people but lack the capabilities (yet) to pursue a career in Nursing, such as Healthcare Support Workers and Nursing Associates...both of which are important support roles and can enable those who wish to to move onto a Nursing degree at some stage.

I am perplexed why Nursing is the only profession which is thought not to need skills learnt through higher order learning such as: articulating what you know, insight, analysis, evaluation and critical reasoning. Education is about learning how to think and there is an increasing amount of evidence that recognises the higher the level of education in the workforce, the better outcomes there are for patients. My profession works alongside yours for a common purpose: to ensure children live as healthy and long a life as we can enable for them. I respect your profession requires years of tutelage and experiential learning to achieve proficiency in doing this; I respectfully ask the same is offered to mine. This is the focus of point 8....to acknowledge that for all professions to strive for excellence, contribute to research and lead change you have to provide opportunities to explore, critique and evaluate what you do and yet this is the first thing to be pushed aside for service needs within Nursing. This is one element of retaining Nurses, recognising they are a profession who require the same opportunities to develop as other professions in healthcare; that is what motivates and validates work.

Fortunately some places are supportive of ensuring this happens but there is more to do...and do it we will.

Best wishes to you Mr Spicer

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