BLOG by: Jane Ball1 & Holly Blake2 on behalf of the ICON Study Team3
1Professor of Nursing Workforce Policy, University of Southampton & NIHR ARC Wessex;
2Professor of Behavioural Medicine, University of Nottingham;
3 ICON Study Team: Led by Keith COUPER, Jill MABEN, Ruth HARRIS, Janet ANDERSON, Daniel KELLY, Anna CONOLLY, Sydney ANSTEE, Murrells, Trevor; Sanders, Julie; Kent, Bridie; Rafferty, Anne-Marie; Taylor, Rachel; Abrams, Ruth; Rowlands, Emma;
The COVID-19 pandemic is an experience we have all shared, with sustained social, economic and cultural effects across the globe. Media coverage through the pandemic has thrust health and care services into the spotlight. The public is becoming increasingly aware of disruption and changed services, exacerbating problems with health service access, diagnostics, waiting times, and care delivery. Workforce shortages threaten the future of health and care services, and we need to focus on recruitment, training and retention of health and care workers, to future-proof our National Health Service.
Nurses and midwives are at the centre of this crisis. Making up almost 50% of the global health workforce, they represent over 50% of the current shortage in health workers. In the UK, there are over 758,000 nursing and midwifery professionals regulated by the Nursing and Midwifery Council. The pandemic exposed existing vulnerabilities in our healthcare systems, and concerns about pay, staffing levels and patient safety have led to nurses’ strikes across the UK set for December 2022.
The UK COVID-19 Inquiry was set up to examine the UK’s response to and impact of the COVID-19 pandemic across England, Wales, Scotland and Northern Ireland, and learn lessons for the future. One of its goals is to examine how COVID-19 impacted on health and care sector workers. But only a few nurses and nursing professional bodies will have been able to contribute to this UK public inquiry. Nonetheless, we have answers from research with a similar goal.
The ICON study gathered views from thousands of nursing and midwifery professionals and students who completed surveys at three time points during the first surge of COVID-19 in the UK. This study showed evidence of psychological impacts, such as stress and anxiety. Notably, almost 45% reported experiences indicative of a probable post-traumatic stress disorder diagnosis. This was linked to being redeployed to unfamiliar clinical areas without adequate training and inadequate infection control training.
In-depth interviews with nurse participants in the ICON study found they were deeply affected by what they experiences and report being forever altered. They struggled with having to provide care in a way that went against their values (known as ‘moral distress’), often due to staffing shortages and managing care of critically ill people under undercertain circumstances. They described care delivery challenges, and experienced emotional states such as compassion fatigue, burnout and trauma. They spoke of the stigmatisation of disclosure of poor mental health. Many had considered leaving the profession.
We often hear of efforts to improve ‘resilience’ in healthcare professions. The ICON nurse interviews also identified that how they conceptualised ‘resilience’ during COVID-19 impacted on their mental wellbeing. In short, nurses (and other health professionals) should not be blamed for not being “resilient enough” or feeling stressed and distressed in response to a crisis situation. Arguably, these are normal and appropriate reactions given the extreme circumstances and context of the COVID-19 pandemic.
So, what can be done?
One question on the ICON survey specifically asked nurses and midwives to tell us the top three things that the government or their employer could do to improve their working lives. Through a close reading and analysis of their reported views and experiences we set out to better understand the impacts of the pandemic on the workforce, and opportunities that exist for improvement. Over three-quarters of those responding were employed by the National Health Service, with 55% working at staff or senior staff nurse levels.
Analysis of these accounts from nurses and midwives provides valuable insight into key changes required to improve working lives during a pandemic. Their messages are clear: urgent improvements were needed in the provision and quality of personal protective equipment. Failure to meet nurses basic needs to be safe appears to have had longer term repercussions, damaging morale in this vital workforce. They also highlighted the need for more support and better communication.
There is no doubt that the COVID-19 pandemic put global health and care systems under extraordinary pressure, both exacerbating and highlighting pre-existing staff shortages and exposing long-standing deficits and strains in the NHS workforce. The research identified key strategies that could have improved the working lives of the nursing and midwifery workforce during the early stages of the COVID-19 pandemic. Timely implementation of these stragies by Government and employers might have reduced the negative impact of COVID-19 on the retention of this vital workforce.
But why were these voices not heard at the time?
According to Ramussen and colleagues’ editorial ‘We’re on mute!’ nursing input was absent or largely invisible during the pandemic. They argue that is less a reflection of the lack of willingness of nurses to contribute and speak-up, but more of the inability of bodies with authority and power to shape health care and to listen, and hear the views of nurses.
Given the stark increase in the number of nurses leaving the profession (one in nine over the last year, in England and Scotland alone) and as nurses across the UK embark on strike in December 2022, we ignore their voices at our peril.