In its 2017 report, the Nursing and Midwifery Council (NMC) (2017) stated that more nurses were leaving the register than joining for the first time in recent history. The main reasons cited for leaving were working conditions (including staffing levels, workload and working patterns), changes in personal circumstances (such as ill health or childcare responsibilities), and disillusion with the nursing care patients receive.
These reasons align closely to Health and Safety Executive (HSE) recommendations (2009) relating to the psychological wellbeing (PWB) of any workforce. The relationship between employees and their line managers is a strong predictor of PWB (Griffeth et al, 2000). Developing ward managers and nursing team leaders to focus on the HSE key areas in promoting PWB may be the first step towards reducing the numbers of nurses leaving the register.
‘Leadership at all levels’ has been widely adopted within the NHS as a key philosophical approach to health care (The King's Fund, 2013). This is extremely important in enabling nurses to cognitively and emotionally assimilate the responsibilities of nurse registration. The artistry of nursing is found in interweaving the principles of care, compassion, competence, communication, courage and commitment (the 6Cs) (Department of Health and NHS Commissioning Board, 2012) into all areas of practice. Nurse leaders need to integrate these same principles into every interaction they have with nursing staff to begin to address PWB.
With a direct channel to senior management, ward managers have a pivotal role to play in balancing the requirements of the organisation with the care for patients and support for staff (Maben et al, 2012). Ensuring that these individuals are appropriately selected, developed and supported is key to the creation of a workplace culture conducive to PWB.
The last few years have seen a significant rise in initiatives such as strength-based recruitment (Fenton, 2014) and leadership development (The King's Fund, 2011) across the NHS, particularly at ward manager level. These initiatives are all aimed at raising the standard of leadership (Hill, 2017), and building democratic relationships with staff more conducive to an engaged and empowered workforce. However, the NMC report (2017) suggested that these aims are missing the mark and nursing remains a largely hierarchical and disempowering culture.
Ward managers are struggling to find time to provide meaningful support for their staff (Stephenson, 2018). A major paradigm shift is required whereby they are given supernumerary status to address the key determinants of PWB. Support is also required to ensure that they can effectively carry out the management aspects of their role while maintaining their credibility as leaders (Johnson et al 2018: 128).
Support and investment from senior NHS management is urgently needed for formalised and sustained programmes of leadership, coaching and mentorship for ward managers, plus supervision, to enable them to effectively and confidently lead a strong, professional workforce. This would contribute to a more flexible, transparent and equitable approach to leadership, with a style more conducive to PWB.
Nurses are the connective tissue of the NHS and should be a stronger force for change. By strengthening nurse leadership in the right way, we can make significant moves towards strengthening the profession, ensuring that nurses remain with us, feel valued and practise creatively and autonomously. If we can address this at ward level, surely this would help ensure that we do not witness a further exodus of nurses from the register.