Even before the coronavirus pandemic, nurses and midwives were reporting high levels of work-related stress, burnout and mental ill health. The pressures of managing Covid-19 mean these challenges are only likely to have been amplified, argue Dr Kevin Teoh, Professor Gail Kinman and Professor Anne Harriss.
Before the Covid-19 breakout, we were commissioned by the Royal College of Nursing Foundation (RCN) and SOM (the Society of Occupational Medicine) to review the literature that examined the mental health and wellbeing of nurses and midwives in the United Kingdom.
The review found exactly 100 relevant studies published between 2009 and 2019 and highlighted worryingly high levels of stress and burnout linked to challenging working conditions such as increased demand and diminishing resources.
About the authors
Professor Gail Kinman is visiting professor of occupational health psychology and Dr Kevin Teoh is a lecturer in organizational psychology, both at Birkbeck University. Professor Anne Harriss is emeritus professor in occupational health and president of SOM (the Society of Occupational Medicine)
Although some intervention studies that aimed to enhance mental health have been published, little evidence was found that they actually work. These findings are of serious concern, and it is clear that the current pandemic will intensify the risks for the wellbeing of nurses and midwives.
The state of mental wellbeing of nurses and midwives
Nurses and midwives are at high risk of work-related stress, burnout, and mental health problems, with between 30% and 50% of nurses and midwives experiencing poor mental wellbeing.
Midwives and emergency care nurses appear to be at greater risk for developing post-traumatic stress, while female nurses are at a comparatively higher risk of suicide (Windsor-Shellard and Gunnell, 2019).
Crucially, evidence was found that nurses and midwives typically report poorer mental wellbeing than the UK general working population or samples of nurses from other countries.
For example, one study reported that the prevalence of burnout among 2,918 nurses in the UK (40%) was higher than that of nurses from the ten other European countries included, the average prevalence of burnout for the whole sample was 28% (Heinen, Van Achterberg and Schwendimann et al, 2013).
In spite of the risks to wellbeing, it is important to note that nursing and midwifery is seen by many staff to be satisfying and fulfilling. This is seen in data from the 2018 NHS Staff Survey (NHS Staff Survey Coordination Centre, 2019) which shows that nurses and midwives report higher levels of engagement than most professions within the NHS and that these figures are equivalent to that in the general working population (Bonner, 2016).
Few studies focus on positive manifestations of wellbeing, however, and, while certain positive traits (such as optimism, self-efficacy and resilience, and problem-focused coping) can be beneficial, we still know little about the individual and organisational factors that underpin positive wellbeing and optimum functioning in nurses and midwives.
It is important to note that we found little evidence that individual factors, such as personality and demographics, are a key contributor to poor mental wellbeing. Instead, work factors are much stronger predictors of outcomes such as stress and burnout. In particular, workload, administrative demands, lack of support and experiencing trauma are particularly strong contributors.
This is not surprising, given that one study reported that nine out of ten nurses had to work through their breaks and 55% did not have enough staff on their last shift (Marangozov, Huxley, Manzoni, and Pike 2017).
Nurses and midwives are at high risk of harassment and bullying from patients, colleagues and managers and this is a key source of distress. Of particular concern is that such experiences are more common among staff from BAME backgrounds.
In terms of working conditions more generally, levels of satisfaction with demands, control, support and role clarity are all lower than the UK average. Worryingly, demands appear to be rising in line with reduced staffing levels and other resources, while there also appears to be an increase in the incidence of harassment and bullying.
The impact on personal life and work-life balance
Work-life balance is generally poor among nurses and midwives and is a key source of stress. Longer shifts not only constrain opportunities for rest and recovery, but also impair mental health, wellbeing and job satisfaction. Also important is the low satisfaction found with training and advancement, as well as substantial financial pressures perceived by many nurses and midwives.
One RCN survey found that 61% of participants considered their pay to be inappropriate, with 56% having to cut back on food and travel costs, 23% taking an additional job, 21% struggling with utility payments and 2% receiving support from food banks or charities (Marangozov, Huxley, Manzoni and Pike. 2017).
These findings are not only of considerable concern to a high proportion of nurses and midwives, but having to take on additional work creates further demands while at the same time further constraining opportunities for rest and recovery.
Why mental wellbeing is important for nurses and midwives
What impact does the mental wellbeing of nurses and midwives have more generally? Surprisingly, the link between nurse and midwife mental wellbeing and patient care has not been as widely examined or firmly established as it has been among doctors, or cross-disciplinary samples of healthcare workers.
Although clinical care outcomes have been examined in other studies involving nurses, particularly in relation to nursing staff levels, they have not been have not been assessed as an outcome of nurse and midwife mental wellbeing.
Nevertheless, there is evidence linking poor mental wellbeing among staff to self-ratings of lower quality care outcomes and patient safety at both the individual and ward level. Apart from poor mental wellbeing, higher levels of engagement among the 42,357 nurses and midwives who responded to the 2011 NHS Staff Survey in England were strongly linked with perceptions of personally providing better quality care to patients (Shantz, Alfes, and Arevshatian, 2016). It is important to note that this relationship is also likely to be reciprocal, as engagement and better-quality care can be mutually reinforcing.
We found that exposure to suffering in high-stress environments can lead to compassion fatigue among nurses and midwives, with serious implications for staff and patients.
Providing patient-centred and compassionate care is fundamental to nursing and midwifery and laudable. Nonetheless, it is crucial to recognise that emotional labour is a key aspect of the job and this can lead to emotional exhaustion. There is also evidence that nurses and midwives are at particularly high risk of compassion fatigue and this can increase the likelihood of burnout. Appropriate support is therefore needed to help offset this risk (Kinman and Leggetter, 2016).
Good mental wellbeing is also important for the retention of the nursing and midwifery workforce. Failure to retain or to keep the workforce healthy only accentuates staff shortages that further compound the demands faced, creating a rapid downward spiral that is not sustainable.
Poor retention involves further costs to healthcare in terms of loss of experience, expertise and oversight. This is concerning, particularly as 67% of nurses and midwives report thinking about leaving the profession (Royal College of Nursing, 2013), while 37% have been looking for a new job (Marangozov, Huxley, Manzoni and Pike, 2017). Poor mental wellbeing is a major push factor, with nurses experiencing burnout more than twice as likely to consider leaving (Yoshida and Sandall, 2013).
Nurses and midwives are at particular risk of presenteeism, with between 59% and 82% of nurses and midwives continuing to work while unwell. Presenteeism is closely linked to mental wellbeing, as nurses and midwives may be discouraged from taking time off work due to stigma, not wanting to let patients and colleagues down, or not being able to afford to be off work.
It is therefore crucial to recognise that presenteeism has serious implications for patient care, as when workers eventually go off sick they tend to be absent for a longer period, highlighting the importance of exploring this issue further.
Building a positive culture within health care settings
When considering interventions to support the mental wellbeing of nurses and midwives, the majority of initiatives were what would be considered secondary or tertiary type interventions.
Secondary interventions help an individual deal more effectively with challenges, or help mitigate the impact of negative events or circumstances, while tertiary interventions focus on rehabilitation and restoration to help people return to work.
We found a range of individual-level interventions that have been carried with nurses and midwives, including psychoeducation classes, mindfulness training, reflective group practices and self-compassion training, in addition to initiatives that aim to enhance workplace skills and knowledge. Generally, the evidence shows that these can be effective, but any benefits tend to be short-term and does not usually transfer to better patient care.
What is overwhelmingly missing from the literature are primary-level interventions, which involve changes to the work environment to reduce hazards at source and create healthier working environments. These initiatives generally focus on reducing demands wherever possible, and/or, increasing the resources available to staff.
There is firm evidence that multi-level interventions are most effective in improving the wellbeing of employees, so primary interventions that focus on prevention should be complemented by secondary and tertiary interventions to offer a more comprehensive approach.
We found three smaller-scale primary-level interventions carried out with nurses that showed some beneficial outcomes. The key to success is to have a good understanding of what the underlying issues are initially, followed by deciding what change to prioritise, consulting and involving both staff and managers, carrying out the change, evaluating what happened, and learning from the process.
Monitoring and enhancing mental wellbeing is not something that is ever completed though; initiatives should be part of a continual and ongoing process which involves learning from the previous efforts to improve future initiatives.
At their core, primary interventions should be based on appropriate organisational policies, ensuring basic necessities are met, and providing appropriate resources and training to managers. A participatory approach that involves nurses and midwives at all stages is imperative, as they are best placed to identify issues and solutions and this process encourages ownership of change initiatives and minimises resistance.
Underpinning all efforts to improve mental wellbeing is the need to address stigma and accessibility. Unfortunately, a body of research indicates that disclosing mental health problems is still widely stigmatised among healthcare workers and many are therefore reluctant to access support. Staff may feel that seeking support signals a “failure to cope” that may be judged negative by the individual and others. An inability to self-refer and not having access to on-site are further barriers to help-seeking.
An important factor that encourages action is accessibility, so staff must be given sufficient time and opportunity to take up training opportunities or to access interventions and support. Key issues include whether support is available on site, who controls access to support, how long waiting lists are and whether appropriate support is even available.
More basic factors that discourage uptake are evident where nurses and midwives do not have the opportunity during shifts to engage with support initiatives and do not have the time or energy to access sessions outside of working hours.
Engaging with occupational health can be difficult if practitioners lack the expertise to support employees’ mental health, are under-resourced, or they have little understanding of, or influence over, the working conditions of nurses and midwives who are seeking help.
A note of caution
Reviews are only as good as the data that is available. From our examination of the literature and subsequent discussions with stakeholder groups, it is evident that there are clear gaps in the research.
These include a lack of research linking nursing and midwife mental wellbeing to objectively measured patient care outcomes. Crucially, few studies have explored the experiences of ethnic minority nurses and midwives in the UK and how this impacts on their wellbeing and practice.
This is a major concern, given that a substantial proportion of the workforce has an ethnic minority background. Research from other fields not only demonstrate that ethnic minority workers report poorer work experiences but, as the Covid-19 pandemic has brutally exposed, they are at disproportionally higher risk of poor health outcomes.
The views and experiences of other groups are also largely missing, including older nurses and midwives, male nurses and midwives, and those who do not work in NHS or acute settings.
The implications of women’s health issues are also of major interest, given that nurses and midwives are predominantly female, and the workforce is generally ageing. Both research and practice need to account for these issues when trying to develop a more inclusive workforce.
Finally, we have little knowledge of the longer-term impact of Covid-19 on the working conditions and wellbeing of nurses and midwives as well as the implications for their personal lives and for society in general.
The elephant in the room – Covid-19
This review is derived from research carried out before the Covid-19 pandemic. There is no denying that things did not look good before the outbreak, and the outlook for the wellbeing of healthcare professionals moving forward is undoubtedly bleaker.
The substantial demands and challenges experienced by healthcare staff will have been intensified by Covid-19. Longer working hours, more physically, emotionally and mentally draining work, having to socially distance, additional caring responsibilities in one’s home life, or having to live apart from one’s family are among the additional demands from Covid-19 that compounds the difficulty in achieving a healthy work-life balance and increases the risk of burnout.
It is also important to recognise, however, that this upheaval has presented some opportunities for improvements, as in some settings there is additional capacity and resources and a reduction in bureaucracy. Importantly, there is a greater focus on the importance of mental wellbeing that will help destigmatise help-seeking.
Now, more than ever, we must prioritise the mental wellbeing of our nurses and midwives, identify and implement appropriate interventions and improve the environments in which they work. It is vital to build a culture within healthcare organisations that explicitly recognises how the nature of the work and current working conditions can impact on the wellbeing of staff.
We know that many are already struggling and, if urgent action is not taken immediately, the long-term impact on the workforce, the healthcare system and wider society will be catastrophic.
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