The Trouble in Nursing….

The nursing profession has reached a crisis point we simply cannot ignore what is happening in the profession any longer.

I recently read a post in an American journal the Minnesota reformer, that was written by a junior nurse. In the article, she talked about how all she had ever wanted was to be a nurse. She had resigned from her role as she felt that senior management was not taking her safety concerns, particularly the shortage of staff on each shift seriously. Sadly this situation is replicated in the UK, Australia and many other healthcare systems globally.

The cost of losing just one nurse

For an organisation to lose just one nurse is one too many in my view. In Australia, an average undergraduate degree in nursing will cost an individual approx $20,000- $35,000 AUS depending on which university you study at. The cost to a health care organisation in Australia of a new graduate nurse leaving the profession amounts to between 30-50% of their annual salary to replace them (APNA). The more senior the nurse the greater the percentage of their annual salary to replace them.

I am very saddened by what is happening to the Nursing profession in this post-Covid world, which I know is a global issue. Nursing has been and continues to be taken for granted for far too long. Covid highlighted and exaggerated the cracks that had started to appear in the profession long before Covid arrived.

Most trusted profession

Nurses globally hold the position of the most trusted profession in the eyes of the public. During the pandemic, we clapped and cheered and lit up important buildings in our respective country’s health colours. Nurses, it seemed were held in high esteem for being angels of mercy at a time when the world was dealing with the pandemic. Maybe part of the problem in nursing is the public perception of nurses as angels; I’ll come back to this point later.

Moral Injury

Social media was flooded with photos of Nurses who bore the scars of wearing PPE for many hours on end, exhaustion was evident as was the moral injury of caring for so many very sick and dying patients whilst trying to navigate doing all this from a place of care and compassion for the families of those patients during the lockdown.

Yes, nurses did go the extra mile and some. They worked double shifts and more. Nurses had to sacrifice family life to avoid spreading Covid to their loved ones. Those nurses who weren’t fighting the cause on the front line were busy behind the scenes with mass testing and vaccination. Globally nurses made a significant contribution to the war against Covid-19. Did we ever stop to even contemplate what that war would have looked like without the global mobilisation of the nursing workforce?

Tsunami of discontent

Fast forward to the end of 2022 and a tsunami of discontent is brewing in the Nursing profession that seems to have taken organisations by surprise. Nurses in Australia, the UK and America are considering or have already taken strike action to make a point about pay and conditions that need to reflect the weight of the moral injury sustained during covid.

Strike action is not something that nurses take lightly. It is almost always a last resort when governments and healthcare organisations a) fail to recognise the gargantuan scale and effort that was required from nurses and nursing that was provided relentlessly during the pandemic and b) refuse to listen to the justification for pay awards in line with the ever-increasing cost of living.

It is pretty simple really. If you continually ask a professional to go over and above with limited resources in terms of materials and people you will create a pressure cooker effect. Something somewhere will have to give and that something is nurses who are leaving the profession in droves and are burnt out and done with nursing.

A quick scan of a few nursing groups on social media would seem to support this view. Many nurses are seeking advice about what other careers might be possible with a nursing qualification. There continues to be an exponential rise in the number of nursepreneurs; nurses who are leaving to set up their businesses or reducing their hours to enable the running of their businesses.

Consequences of nurses leaving the profession

To stand back and take a global perspective for a minute is to understand that globally the world’s population is ageing. We are approaching a point in the not-too-distant future where there will be more people in retirement than in employment. This is not a new fact. Governments worldwide have known about this for decades. The important fact to remember here is that with the increase in global ageing comes an increase in long-term conditions associated with ageing. An increase in long-term conditions means that more nurses and carers will be required to care for a predominantly ageing population.

Pre covid

The International Council of Nurses (ICN) identified that the world was already short of 6 million nurses even before the pandemic. Globally there are at least 10 million nurses who will retire in the next ten years (ICN). Nursing as a career choice has taken a hit with young people considering alternative career choices rather than nursing per se. No doubt discouraged by the ravaging of the profession during and beyond covid. These figures in themselves are seriously alarming even without factoring in the mass exodus of nurses that continues and will continue long after covid has diminished.

It is important to note that solving the mass exodus will not happen overnight. It takes three years to train a nurse and another year to support them in a graduate role. Overseas recruitment is an option but all that we are doing here is depleting the nursing workforce in other countries. Shuffling nurses from one country to another with the promise of better pay and conditions is a risky move in itself. It doesn’t matter how many nurses we recruit, if we are not looking after them and supporting their growth and development then they too will leave their positions, disillusioned, weary and burnt out.

Moral injury following covid

If we turn our attention to the current state of moral injury and rates of burnout in the profession this highlights the problems within the profession even more.

The ICN data shows that in the first wave of the pandemic the proportion of nurses reporting mental health distress rose from 60% to 80% in many countries globally. In Australia in 2021 61% of Australian nurses reported burn out with 28% reporting depression (ANMF South Australia)

When you take a global view of the situation in the nursing profession, you can begin to see the interconnectedness of the current worrying situation in Nursing. Nursing is being hit on all fronts. Simply put healthcare organisations cannot afford to lose nurses without a contingency plan in place to determine who will become the carers in the absence of nurses. It is not an option to sit back and allow the continuous haemorrhage of nurses from health care, whilst thinking there are plenty more nurses who will want to come and work for their respective organisations.

Nurses as Angels

The case of RaDonda Vaught in America who was criminally convicted for a fatal medication error shocked many nurses. There were many posts on social media at the time where nurses were saying that that scenario could have happened to any one of them. This case sent shock waves through the nursing profession. Instead of learning from a fatal medication error to implement changes to prevent this from happening again. It became a who’s fault is it by the health care organisation concerned, who then pursued a criminal conviction against RaDonda. Suddenly the image of a nurse was not looking so angel-like anymore.

A lot has changed since I started my Nurse training 40 years ago. My training was old-fashioned by today’s modern standards. I can remember at 18 feeling terrified that I was either going to hurt someone or pass out at some of the things that I saw and assisted with. As a young trainee nurse, I thought I knew what I was getting into wanting to be a nurse but nothing could have prepared me for the reality of nurse training. Nursing taught me to grow up very quickly over my three years of training.

The biggest lesson was that life is short and to make the most of it. What I did have that made a difference was great support from clinical teachers that were ward-based, good skills mix on the floor, senior experienced nurses who knew their stuff and a ward sister who was present and oversaw patient care.

Modern-day nursing

Modern nurses are highly trained, technically savvy, and experts at problem-solving and dealing with complexity. They are skilled communicators, navigators and advocates for patient care. Nurses undertake large amounts of professional development to maintain their annual registrations. Nursing is complex and varied and there are so many career pathways that nurses can consider now compared to a few decades ago. The professionalism of Nursing through degree entry programs and training has helped to achieve this. There is work to do about changing the public perception of a nurse who is an angel to understanding that today’s nurse is a professional and highly trained and educated nurse in their own right. I’m not advocating that we go back to the good old days at all, but there is something back there in how junior nurses were nurtured and supported back then that we seem to have lost today.

Support for Graduates

As part of giving back to the nursing profession, I mentor nurses who have just graduated or who are undertaking professional development in nursing leadership. The alarming thing that I am noticing here is the number of nurse graduates who start a new role and then leave within the first few months. The reasons given follow the same themes, lack of support, not enough staff, and no senior nurses. One graduate told me that often she could be the most senior nurse on the floor a year out from graduating. Bullying behaviours from senior nurses and a feeling that their training has not prepared them realistically or adequately for the pressures that exist within nursing today.

Attrition rates amongst graduate nurses

Given what I identified about the financial cost of one graduate nurse leaving, we are talking about many graduate nurses who choose to leave very early on in their careers. Maybe graduate attrition rates could be a metric that is made available to the local communities so that people can judge for themselves who is supporting the nurses of the future and who are not. Why are we not understanding why our graduate nurses are leaving and putting measures in place to support them based on their feedback? We cannot afford to keep losing our graduate nurses who quite simply want to be a nurse.

Nursing is a tough career choice and it is not for everyone. It takes a special kind of person to train to become a nurse. This special kind of person is one that any one of us would want to care for us when we are seriously sick or injured.

Preparation for leadership

Part of my passion for making coaching accessible to nurses is to help nurses who are new to a leadership role is to help them develop a toolbox that can help them in their role. There are many in-house leadership courses for nurses that are developed and run by nurses. Many nurses are unprepared for the reality of moving off the floor as a clinician into a leadership role. Often they feel like an imposter because they don’t know what they don’t know; their words, not mine.

In-house leadership training

I would argue that in-house leadership training does not equip nurses who are moving into a management or leadership role with the necessary skills for the role. Skills such as how to have a difficult conversation, how to provide balanced performance feedback, how to manage poor performance, how to set boundaries around your time, and how to stay connected to your team when you are pulled in so many directions running from meeting to meeting. How to manage conflict in teams. How to recruit successfully to teams that complement the values and skills that are already on the team.

Nurses are sick and tired of hearing about resilience. Being told that you need to be more resilient does not help you to understand what resilience is. It is not something that you either have or don’t have but is something that can be learnt and developed to help you cope with and respond to change, helping you to understand what you can do to develop your resilience and that of your team.

How to influence successfully

Generally, we don’t teach nurses how to influence at the executive or board level so that a nursing voice is heard where it needs to be heard the most. We don’t teach how to collate and present data to support an argument for more resources and improvements to patient care. We also don’t teach how to manage budgets effectively or how to understand the intricacies and politics of how health care is funded.

A great deal of money is spent learning about our personality types but not about understanding the personalities of our team members or how to communicate effectively with them. I recently had a conversation with someone working in healthcare who said that their organisation had no in-house training for how to manage conflict in teams. Healthcare is made up of teams who work together to support patient care. I know from personal experience just how much time and resources are spent by managers and the HR departments managing conflict in teams. There is a need to modernise the training that is provided in-house to equip team members with the leadership skills required to work in modern-day healthcare.

Pay

Pay is only part of the solution here. What nursing needs is innovation that is led by the clinicians and teams and supported by executive nurses and thought leaders and academia. We need to draw on those healthcare organisations globally along with C-suite business acumen and experience. To learn from the best in terms of those organisations that are excelling with work-life balance, and staff satisfaction and have great recruitment and retention figures to consider what can we learn and apply to our respective health care organisations globally.

Patient Acuity

We need to find new ways that accurately reflect patient acuity to be then able to work out how many nurses are needed to care for those patients based on acuity. The old ways of nursing hours per patient day do nothing to help a senior nurse argue for more resources based on the acuity of the patients on the ward. It has become a subjective exercise as to what high acuity is to a nurse which may be viewed differently by a manager who is struggling to staff a hospital.

Gen Z

Here’s the thing today’s Gen z’s are not going to buy into the perception of nurses as angels. This perception of nurses and nursing is vastly outdated and doesn’t reflect the modern-day nursing careers that are dealing with increasing co-morbidities and complexity as the population ages. Neither are they going to put up and shut up. They are and will continue to vote with their feet.

In summary

I have said this before but will say it again; those organisations that look after their staff and support them will become employers of choice in a world where there will be competition to recruit from an ever-diminishing pool of nurses.

What is happening in nursing is a serious wake-up call for every healthcare organisation globally. If we don’t act now there will not be enough nurses to meet the demands of an ageing population that includes me and you and that is a world that I never want to see.

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