A new report from The King's Fund (West et al, 2020) focuses on the impact that the COVID-19 pandemic is having on the nursing, midwifery and social care workforce and looks at how workplaces can be transformed to enable staff to deliver compassionate, high-quality care. The review, The Courage of Compassion: Supporting nurses and midwives to deliver high-quality care, was commissioned by the independent charity the Royal College of Nursing Foundation (which is part of the Royal College).
Background
The King's Fund was founded in 1897 with a primary mandate to raise money for London's voluntary hospitals. Today, the charity's wide-ranging activities are oriented towards influencing the development of health care and fostering good practice throughout the NHS.
It aims to influence healthcare development at all levels from national policymakers through to helping frontline staff deliver optimum care in hospitals and the community. Under the banner ‘Ideas that change health and care’ the charity's website (https://www.kingsfund.org.uk) is a repository for a wide range of useful documents, blogs and audio recordings that provides a wealth of information for nurses and others in the healthcare team.
The latest review reminds readers that the workforce had been under significant strain even before the onset of the pandemic. By early 2019 high levels of stress among staff, coupled with absenteeism and high staff turnover, were at alarmingly high levels, with large numbers of nurse and midwife vacancies across the health and care system. Data from the National Audit Office (2020) reveal that there were 43 590 full-time equivalent nursing vacancies in NHS trusts between July and September 2019.
The King's Fund review reveals that the current pandemic has had an unprecedented impact on the nursing workforce and exacerbated pre-existing factors, such as career inequalities, inadequate working conditions and chronic excessive work pressures.
However, it is not the first time that a pandemic has had such a devastating effect on the health and wellbeing of frontline nurses. Medical historian Mark Honigsbaum (2020) writes that countless numbers of hospital nurses became ill and many died during the Spanish flu pandemic of 1918 after contracting the virus in the line of duty. Then, as in the current pandemic, the health and wellbeing of nurses was crucial to the quality of care they could provide, affecting their compassion, professionalism and effectiveness in practice.
The review
Environmental factors
The review seeks to illuminate how nurses' and midwives' workplaces can be transformed to better expedite the delivery of high-quality care. Kieft et al (2014) defined a healthy work environment as one in which nurses are both able to meet the aspirations of their healthcare organisations and gain individual gratification from their nursing care delivery. Healthy and satisfying work environments engender an atmosphere whereby nurses are enabled to fully apply their expertise, skills and clinical acumen in caring for sick people and providing patients with optimum nursing care.
According to Neill (2011), work environment factors, such as good managerial support and good collegiate teamwork, can make a major contribution to individual job satisfaction.
Stress and burnout have been widely discussed in the nursing literature over the past three decades, with workload, managerial style, conflict in the workplace and the emotional cost of caring for the seriously ill all acknowledged to be major contributors. Other possible contemporary factors linked to burnout are changes in shift patterns, ie the move to 12-hour working and a lack of tangible rewards within the profession (McVicar, 2003).
The ongoing COVID-19 pandemic is putting nurses under huge pressure and in some cases claiming their lives. Up until August 2020 more than 620 NHS staff and social care worker deaths had been linked to coronavirus (Lintern, 2020). More recently, in October, a nurse lost her battle with COVID-19 in the Nightingale Hospital in Belfast (Birchley, 2020).
Mental health and wellbeing
The King's Fund researchers set out to explore the causes and ramifications of poor mental health and wellbeing among all nursing and midwifery staff and students, healthcare assistants and nursing associates, across the UK. Evidence was sourced from a review of the literature and qualitative data from focus groups comprising nursing and midwifery staff. Additionally, semi-structured interviews were conducted with key stakeholders from across the four UK nations, with nurses and midwives from a range of seniority levels, representative bodies and royal colleges, government departments, regulators and improvement bodies, and workforce leaders.
The researchers suggest that making changes in the workplace environment will support nurses to better provide the compassionate, high-quality care that they wish to offer patients and service users. The report proposes that three core work needs must be met to ensure the wellbeing and motivation of nurses and midwives at work, and to minimise workplace stress. These are:
The report's authors have formulated eight key recommendations designed to meet these three core work needs.
Key recommendations
Authority, empowerment and influence
Healthcare organisations should endeavour to introduce methods through which nursing and midwifery staff can make major contributions to influence the cultures and processes of their organisations. Furthermore, staff should be enabled to participate in decisions about how care is structured and delivered.
Justice and fairness
Healthcare organisations should embrace concepts that are fair and just, offering psychologically safe environments that ensure equity, diversity and universal inclusion.
Work conditions and working schedules
The review recommends the introduction of minimum standards for facilities and working conditions for nursing and midwifery staff in all health and care organisations.
Teamworking
Health and care services should develop supportive and effective multidisciplinary teamworking for all nursing and midwifery staff.
Culture and leadership
Organisations should take steps to ensure that all health and care environments embrace compassionate leadership and supportive cultures to enable staff to deliver high-quality, continually improving and compassionate care.
Workload
Organisations across the care sector must fundamentally address chronic excessive work demands that exceed the capacity of nurses to sustainably lead and deliver safe, high-quality care and that potentially damage their health and wellbeing. In context, it is important to recognise that, when the Care Quality Commission inspects an organisation such as an NHS trust, the specialist advisers inspect the off-duty rosters to ascertain whether the clinical area meets staffing guidelines, such as those produced for example by the Royal College of Nursing (2020) and the British Association of Perinatal Medicine (2019).
However although these and other staffing guidance polices have been incorporated into National Institute for Health and Care Excellence guidance, it should be appreciated that these remain guidance documents only and at present are not mandatory.
Management and supervision
It is vital for organisations to ensure that all nursing staff have the effective support, professional reflection, mentorship and supervision needed to perform optimally in their roles.
Learning, education and development
Fair and equitable outcomes should be a component of the systems, frameworks and processes that should be in place for nurses' learning, education and development throughout their careers.
Conclusion
During the second wave of the pandemic the health and wellbeing of nurses is undoubtedly crucial to the quality of care they can provide because deficits can, and will, impact on their compassion, professionalism and effectiveness. Working conditions should be appropriately configured across all settings, but especially in clinical areas that are seeing large volumes of COVID-19 patients. Such configurations are vital in supporting nurses in ensuring the best patient outcomes.
It is important to remember that the care COVID-19 patients receive is only as good as the nursing staff who deliver it. So who cares for the carers? It is going to require the courage of compassionate leadership across the whole of the health and care sector, and across the whole of the UK, to fully engage with and successfully address the challenges faced by our nursing services. Appropriate actions by nursing leaders and managers to alleviate some of the stresses borne by the nursing workforce will be critical over the coming months as we continue to try to overcome the second wave of COVID-19. It must be clear to all that this will be vitally important in underpinning the ability of the NHS to optimally care for the health and wellbeing of all, not least those members of the workforce who put their own lives on the line every time they turn up for duty to care for those too ill to care for themselves.