Poor staff recruitment and retention is a problem that continues to plague the NHS. In an effort to identify factors that might be associated with poor recruitment and retention, the North Central London Workforce Development Confederation (NCLWDC) surveyed nursing and therapy staff working with stroke patients across north London trusts.
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Yvonne Webb, MSc, BA, DipPsych, is an independent researcher;Ann Stear, RN, RM, RHV, DMS, is former director of nursing, Enfield Community Care NHS Trust (now retired);Jo Pethybridge, SROT, MSc, is team leader, Camden Reach Team, Camden Primary Care Trust, London;Ruth Baker, MCSP, is head of therapy services, Haringey Primary Care Trust, London;Gina Elharch, MSc, BSc, RN, RM, is stroke lead nurse, St Ann’s Hospital, Haringey Primary Care Trust, London
Over 300 nursing and therapy staff - including occupational therapists, physiotherapists, speech and language therapists, and dietitians - completed a short questionnaire about their work. The research focused on staff who cared for stroke patients, whether on specialist or non-specialist wards and units. However, stroke patients are distributed across a range of wards and units, so it is fair to say that the sample was reasonably representative of clinical staff who work in London trusts.
Most staff, particularly nurses, were proud of their jobs and felt committed and motivated. They got on well at work, few experienced bullying or harassment from patients, carers or other staff, and most felt sufficiently trained to do their work (although many had not received training in specialist stroke care).
There were some problems associated with lack of role recognition, autonomy and decision-making. Most were dissatisfied with their pay and many felt that they often could not do all they needed to during their shift and consequently felt under pressure.
Participants were also asked about their health and well-being. Most reported good health, but 27% reported feeling miserable and anxious at least some of the time, and these statistics were similar for both therapy and nursing staff. However, only half the nurses felt that they were on top of things, compared with 68% of therapists. About 30% of nurses and 27% of therapists regularly felt unhappy with the way their life was going and many reported low energy levels.
More than 31% of therapists and 47% of nurses who had been off work in the previous six months cited stress (defined as feeling anxious, miserable and tense) as the reason for the absenteeism. Most of this group felt that their stress was work related (Fig 1). The research showed that nurses were more likely to take sick leave, to be off for longer and more likely to report work-related illness (39%) and work-related stress (42%) compared with therapists (at 25% and 20% respectively).
It could be argued that it is easy for people to say they are under stress and to use it as an excuse to take time off work. However, mental health nurses who took part in a pilot a few months before the main survey reported similar levels of general stress, but very few cited it as the reason for being absent. The main differences between the groups were that the mental health nurses who took part in the pilot had more autonomy (79%) and felt more involved in decision-making (86%), as opposed to the nurses who took part in the survey (52% and 55% respectively).
This suggests that the need to take sick leave is influenced by the type of work and the environment on medical and elderly wards compared with mental health nursing. Given the higher sickness levels among nurses on medical and elderly wards, it is worth investigating the causes of stress and whether nurses are reluctant to discuss it other than in general terms.
Inherent job stresses
Menzies Lyth (1988) found intrinsic stresses within the day-to-day work of general nursing that had profound implications for nurses’ well-being. This observation was before the era of inadequate staffing levels, agency nursing, clinical audits, frequent policy changes, litigation and media intrusion. Her team looked at why nurses in a typical general hospital seemed to experience much greater levels of stress than would have been expected.
The researchers identified nursing tasks, such as administering bedpans, enemas, wiping bottoms, dressing wounds and caring for chronically ill and dying patients over prolonged periods, as potentially deeply disturbing. Most nurses got on with it but thought that much of what they did was distasteful and frightening. However, they rarely discussed it with each other or received any support for their emotional needs.
Nurses are particularly vulnerable as, unlike most medical and therapy staff, they are confined to the ward for the duration of their shift. In the NCLWDC survey, a third said that they did not get adequate breaks during shifts.
When observing nurses on a cardiac ward, Skogstad (2000) encountered a sophisticated set of techniques to fend off painful feelings around patients. These included ‘pity and sadness, resentment, guilt, fear of illness, contagion and death, doubts about one’s ability to care for the patients and to keep them alive, and helplessness’.
He noted that the nurses were also subjected to the equally painful emotions of the patients and their relatives. Defensive strategies used by nurses included:
- Moving patients unnecessarily;
- Avoiding talking intently to patients (and preventing juniors from doing so by keeping them occupied with practical tasks);
- General hyperactivity (sometimes manic);
- Flirtatiousness between staff during moments of tension and crisis.
Research has shown that staff caring for older people grapple with anxieties about ageing, being worthless and abandoned (Roberts, 1994), and have to cope with deep anxieties about death (Ramsey, 2000).
Because a lot of nursing in acute NHS hospitals is concentrated on caring for older patients with long-term illness and disability, these anxieties may intensify.
When prompted, nurses in the focus groups used in this study expressed profound disturbance about death and dying. It was not uncommon for them to dwell on the death of a patient for days afterwards. Yet all admitted that they neither spoke to each other about these issues nor discussed them during training. They felt that dealing with such issues was part of being a nurse. It is revealing that in Skogstad’s study (2000), when a counsellor was introduced to facilitate staff support groups at the hospital, nurses requested individual rather than group sessions.
Recognition and status
Not all hectic activity is a manifestation of repressed anxiety; there are other common factors that determine much of life on the modern ward. Davies (1995) points out that with the block student system and heavy use of bank and agency staff, a reliance on the task system helps charge nurses to get things done when they have little idea of the competence levels of other staff members. She says the problem with this is that individualised care goals can easily get lost in the daily regime of baths, bedpans and blood pressures.
The pressure and pace of the NHS hospital environment as it bends under the weight of greater demands is well documented. Nurses have never enjoyed high salaries, but in the past they enjoyed public status and recognition. The older nurses in this survey sensed the loss of this public respect. They remembered how, in the early years of their careers, people would give up their seats for them on buses, and the pride they felt in walking down the street in their crisp uniform and cloak.
While the efforts of nurses are still appreciated - one has only to look at the scores of ‘thank you’ cards on ward notice boards - there is a sense that something has been lost. Other career options have risen to take the place of nursing. In the absence of other confirmations of worth, pay has become the focal point of discontent.
It is no surprise that nurses experience stress, although there appear to be differences between different groups. It is possible that the mental health nurses surveyed worked in an environment where expressed emotion was common and therefore they were used to discussing difficult issues. It is apparent that more support is needed to help front-line nurses deal with issues around chronic illness, disability and death. In the face of the particular pressures in the NHS it is also vital to help nurses celebrate their achievements.
There are general occupational support services, such as counselling, available to NHS staff. Some of the participants in this study reported having made good use of them. External counselling services rely on staff approaching them, and focus on the individual’s private difficulties. But when so much of the stress associated with caring for chronically ill and dying patients in a pressured environment is a shared experience, is it fair to expect individual staff to shoulder responsibility for what is, in essence, an occupational hazard? Nurses may not even be aware of the price they are paying in terms of their health.
Recent research has shown that nurses welcome the opportunity to discuss their feelings and their own practice when dealing with clinical conditions that are upsetting and sometimes harrowing (White et al, 1998). Lokk and Arnetz (1997) have shown that emotional and psychological support can reduce stress levels and sick leave.
The government has recognised that caring for staff is crucial to the health of the NHS. Workforce confederations have been set up to take the lead on workforce planning and to ensure that the training and development needs of the staff are met.
The NCLWDC is keen to identify specific training and support needs for staff. This study highlights nurses’ need for training in how to address emotional issues, which could help front-line staff to become more involved in decision-making and to take control of their environment.