British Journal of Nursing - Improving support systems to safeguard the mental health of NHS nurses

Abstract

Emeritus Professor Alan Glasper, University of Southampton, discusses a new government pledge to implement recommendations from Health Education England to better meet the wellbeing needs of health professionals

The Government has made a pledge to revamp the current support mechanisms for NHS staff, such as nurses who experience mental health problems as a result of work pressures. This pledge follows the publication of a report by Health Education England (HEE) (2019) on the mental health and wellbeing of NHS staff and learners, which was commissioned last year. Plans to give staff immediate access to dedicated mental health support will be considered as part of the upcoming workforce implementation plan.

Background

Many nurses and other health professionals work in emotionally challenging situations, providing optimum care to service users day to day. It is interesting to note that the founder of modern nursing, Florence Nightingale, may well have experienced significant emotional trauma during her historic quest to provide nursing care for the sick and wounded during the Crimean War in the mid-19th century. When she returned to England, she was said to have been aged by illness and exhaustion, and suffered long-term depression that only began to abate in her older years (Mackowiak and Batten, 2008).

In contemporary health care it is vital that staff are supported and that employers have the right procedures in place to offer them help when they need it.

The Government is now committed to ensuring that processes are in place to meet the mental health support needs of NHS staff, with recognition that more support is needed for those delivering care and for those studying to become healthcare staff such as nursing students. The main aim of this new initiative is to create an NHS in which staff and learners are content in the work they do, enjoy fulfilling careers and are proud of the care that they provide to their patients.

Many staff in the NHS are exposed to and witness scenes of extreme emotional distress, for example, working with seriously ill children, some of whom may die, and then subsequently being involved in helping the family in their bereavement.

Nurses on the NHS frontline in all clinical environments witness such scenes almost daily. However, the resilience necessary to manage the aftermath of such tragic events is not something that nurses learn during training. The abilities of nurses to cope with such emotional encounters should not be taken for granted and many health professionals need support to prevent them from reacting in ways that are damaging to their own health.

According to Kowalski et al (2010), 15–45% of nurses in hospitals in western countries suffer from burnout. This can lead to emotional exhaustion, depression and a reduction in workplace performance. Preventing this in the nursing workforce is challenging for healthcare managers, not only because burnout can reduce staff retention but also because it can be the cause of preventable serious incidents at work (Kowalski et al, 2010).

It is concerning that nurses' ability to cope in all situations is often taken for granted by the NHS. Given the size of the NHS workforce—it is one of the largest in the world with 1.4 million employees, many of whom work on the frontline of care delivery—it is imperative that the health service should set a precedent when it comes to supporting staff when they need it.

The experiences of healthcare staff in delivering care is critical to their own and their patients' wellbeing, as well as to the overall culture of the workplace (de Zulueta, 2015). The NHS Long Term Plan (NHS England and NHS Improvement, 2019) aims to build a health service that seeks to strive to promote the same values for its staff as they seek to uphold and achieve for their patients.

Key recommendations

The HEE (2019) report on the mental health and wellbeing of NHS staff and learners, which was commissioned by the Department of Health and Social Care, makes a number of recommendations. During the course of the commission's investigation a number of themes emerged, including:

How well children and young people are supported through a range of transitions, such as how they progress through school, then to further or higher education, and subsequently into the healthcare workplace. This reflects the reality that making life transitions can be challenging for reasons that include socio-economic background, cultural diversity or disability

The need for the NHS to support a learning and workplace culture that encourages personal compassion to oneself

Recognising that health professionals are not superheroes and that in health care being a normal human being and delivering high-quality care are not mutually exclusive

A recognition of moral distress, where institutional constraints compromise perceptions of the level of care offered, leading to some nurses developing a sense of personal guilt

Bereavement by exposure, whereby staff who may have been involved in a range distressing scenarios throughout the course of their working lives will have different emotional and psychological needs from those working in non-clinical sectors

The need for nurses to take time out for breaks. In some environments, staff may feel under pressure from colleagues or the workplace culture is to work long shifts without breaks, come to work when ill and even forego annual leave, particularly where staffing skill-mix ratios are suboptimum

Accommodating simple things in the NHS workplace that can make a real difference to staff, such as providing personal lockers, shower facilities, a quiet room, the availability of nutritious food and drink, and a psychologically safe space where nurses can get together with colleagues to talk and to debrief.

For many years the NHS has endeavoured to replicate the success of hospitals in the Magnet^® Recognition Programme, which aim to create supportive professional nursing care environments. In a study conducted by Kelly et al (2016), Magnet hospitals were shown to have significantly better work environments than non-Magnet hospitals and their nurses were 18% less likely to be dissatisfied with their jobs. In context, the better work environments in Magnet hospitals were associated with lower levels of nurse job dissatisfaction and burnout.

Commission recommendations

The Government has made a commitment to implement many of the recommendations of the NHS Staff and Learners' Mental Wellbeing Commission. The 33 recommendations include:

The appointment of NHS workforce wellbeing guardians at trust board level. This recommendation supports a number of principles, but chiefly that the mental health and wellbeing of staff and those learning in the NHS should not be adversely affected by the work they do. The new wellbeing guardians will ensure that, where an individual or team are exposed to a potentially distressing clinical event, time will be given to assess the impact on those concerned. The wellbeing guardians will also implement ‘check-in’ meetings for all new staff on appointment and with all learners on placement. All NHS staff and those learning in the NHS will be able to self-refer to a proactive and confidential occupational health service that promotes and protects wellbeing. The wellbeing guardians will work with representatives of the various regulators, such as the Care Quality Commission (CQC) and the Nursing and Midwifery Council, to ensure that staff wellbeing is given weight in organisational performance assessments. The National Guardian's Office (http://tinyurl.com/nat-guardian-office) has already ensured that Freedom to Speak Up Guardians have been appointed in all NHS and foundation trusts to further protect society by encouraging speaking up in the workplace. It is likely that when the CQC inspects an NHS healthcare facility in future that it will assess the robustness of the new wellbeing guardian processes in the same way as it currently does for the freedom to speak up guardians

The appointment of NHS workplace wellbeing leaders. The initiative seeks to ensure that NHS services appoint wellbeing leaders to work with, and report to, the workforce wellbeing guardians

A further recommendation is that training in self-awareness, self-care, support signposting (for self and peers), and suicide risk awareness and prevention should be explicitly incorporated in all healthcare undergraduate and postgraduate curricula

When capital allocation to NHS bodies is being considered, there should be evidence that estate development plans will enhance or create space for staff and those learning in the NHS. This is a growing area of concern because there has been a steady decline in the provision of psychologically safe and confidential staff-only spaces. The mental wellbeing commission considers it important that NHS staff and students should have suitable accessible to such spaces, where they can rest, socialise, and share and discuss experiences

The mental wellbeing commission recommends adherence to the 2017 government review, Thriving at Work (Stevenson and Farmer, 2017), on the mental health of employees, which provides information on what employers can do to better support all staff, including those with mental health problems, to remain in and thrive through work. Employers should routinely monitor employee mental health and wellbeing.

Conclusion

Healing care environments and buildings are not just for patients and service users, but also for staff such as nurses who work within them. The care that patients receive is only ever as good as the nurse who delivers it and, if the NHS fails to care for the carers, then the whole edifice of the health service could start to crumble.

My own colleague Michael Clift, to whom I dedicate this policy review, sadly took his own life in 2018 after suffering chronic depression for many years. Michael was an esteemed and valued children's nurse who worked at London's Royal Free Hospital as the lead for clinical practice education in nursing across children's services. He was especially interested in providing optimum care for young people with mental health problems. Pertinent to Michael's and many other needless deaths of nursing colleagues is the question: who cares for the people who deliver care 24/7 to the citizens of this country?

KEY POINTS

The Government has pledged to revamp current support mechanisms for NHS staff experiencing mental health problems

Plans are being formulated to give staff immediate access to dedicated mental health support as part of the upcoming workforce implementation plan

Many staff in the NHS are exposed to, and witness scenes of, emotional distress, sometimes on a daily basis

Pivotal to protecting the mental health of NHS staff is the appointment of wellbeing guardians in NHS establishments