Workforce shortages and the resultant impact on nurses (and other healthcare workers), of burnout were cited as the key driver of what was described as ‘an emergency situation’ by a group of MPs who met in June as part of the Parliamentary Health and Social Care Committee (2021).
The committee, chaired by former health secretary Jeremy Hunt, found that gaps in rotas meant the staff who were on shifts were struggling with ‘chronic excessive workloads’. The Royal College of Nursing (RCN) told the committee that, before the onset of COVID-19, the UK had 50 000 NHS nursing vacancies and nearly a quarter of nurses were considering quitting. During an evidence session to the committee, Professor Michael West from The King's Fund explained the links between chronic excessive workloads and burnout. He told the committee:
‘The danger is that we do not see it. It is like the pattern on the wallpaper that we no longer see, but it is the number one predictor of staff stress and staff intention to quit. It is also the number one predictor of patient dissatisfaction. It is highly associated with the level of errors.’
Ford (2021) reported in March that 250 nurses from a London Trust had written a letter of concern. Among the issues raised were that ‘unsafe’ nurse-to-patient ratios during the pandemic had ‘led to severe levels of burnout among staff ’. They wanted ‘strong assurances’ from the trust that it intended to return to the established 1:1 nurse-to-patient ratio in the intensive care unit (ICU) after months of working at 1:3 or 1:4 because of the pandemic. In addition, they said a ‘credible plan’ was needed for how 1:1 ratios would be maintained as elective surgery restarted.
Burnout has been added to the World Health Organization's (WHO) International Classification of Diseases, 11th Revision (ICD-11) as an occupational phenomenon (WHO, 2020). Christina Maslach was the first to propose a theory about burnout and to measure it as a concept distinct from, for example, stress (Dall'Ora, 2020), and developed the Maslach Burnout Inventory (MBI) to measure it (Maslach and Jackson, 1981). According to her theory, burnout is characterised by:
- Feeling emotionally drained (emotional exhaustion)
- Adverse and cynical detachment from patients, clients and colleagues (depersonalisation)
- A lack of confidence in being able to do one's job (reduced personal accomplishment) (Maslach, 1999).
Burnout develops as a result of a prolonged mismatch between an employee and one or more of the following areas (Maslach, 1999; Dall'Ora, 2020):
- Workload
- Control (autonomy in how to do the job)
- Reward (which could be pay, promotion mechanisms, or just recognition of the value of one's work)
- Community (a sense of belonging)
- Fairness
- Values (problems occur when there is no clear mission or vision in the workplace).
The RCN published new workforce standards in May 2021, grouped into three key themes:
- Responsibility and accountability: outlining where the responsibility and accountability lie within an organisation for setting, reviewing and taking decisions and action regarding the nursing workforce
- Clinical leadership and safety: outlining the need for registered nurses with lead clinical professional responsibility for teams, their role in nursing workforce planning and the professional development of that workforce
- Health, safety and wellbeing: outlining the health, safety, dignity, equality and respect values of the nursing workforce to enable them to provide the highest quality of care (RCN, 2021).
The standards provide a very useful holistic framework, with a very clear accountability for executive nurses. In my opinion the real issues are the reality of the baseline, the current demand for both planned and unplanned care, and our real options to mitigate in the short and longer term. I believe that we need a national debate with a wide group of colleagues to consider the issues and realistic practical options that senior leadership teams can viably put into place that will mitigate the risks for both patients and staff—there is no magic answer, but a systematic approach is required.