As a 46-year veteran nurse, who is now retired, I wholeheartedly concur with Tiffin's (2012) statement that nursing is a process that has evolved from the position of a vocation to the status of a respected profession, one in which caring is still fundamentally at its core. It is a profession that has become more complex in ways that could not have been imagined a generation ago – a complexity that has been compounded by elevations in the scope of practice, and perceptions and expectations of the nurse's role, specifically the demand for higher academic achievements (diplomas, bachelor's degrees, and Master's degrees) (Glasper, 2018).
It is my understanding that higher academic achievement not only validates the nursing profession, but also improves the nurse's understanding of the health issues of their patients, enabling them to treat them in a way that will improve their health outcomes and, consequently, their overall satisfaction and experience. Unfortunately, the added pressure of higher academic achievements, including the issues illustrated in Box 1, has been shown to significantly impact nurses' performance as well as their mental wellbeing, and consequently, many have left the profession or are considering leaving (Royal College of Nursing, 2023).
Box 1.Issues that can impact on nurses' performance and wellbeing
- Increased responsibility as a result of the continued changes in the scope of practice
- Increasing workloads, antisocial working, working unpaid overtime, and a stressful and threatening work environment result in increased stress and anxiety levels, and a lack of confidence/poor performance
- Inadequate recruitment and retention efforts resulting in staff shortages and increased work pressures on those remaining, and potential/actual burnout
- Pressures of work result in work-life balance issues, namely the impact on family life
- Feeling undervalued, results in low self-esteem, morale, and self-worth, disillusionment, and reduced motivation and enthusiasm for the job
- The recurring issue of poor pay … increased pressure on managing financial commitments
- Inadequate receipt of emotional and mental health support impacts individuals' ability to cope with increased stress
Many careers websites and online commentators wonder whether salary is, or should be, the most important factor when choosing a career. Kokemuller (2017) argued that salary is significant in the most fundamental sense because it is crucial to be compensated for specific and necessary tasks.
With regard to nursing, arguably in earlier years, salary was not the pre-eminent factor for those entering the profession (it certainly was not in my case). Perhaps for many, the pre-eminent factor was that they genuinely wanted a worthwhile career, helping and caring for the sick in their time of need.
Concerns relating to nurses' pay have been a longstanding issue that has raised questions about whether pay is reflective of the individual's role, status, or worth (Patterson, 2012). Over the years numerous pay initiatives have been introduced, one of which was the introduction of clinical grading in 1988. This scheme resulted in an overwhelming majority of nurses appealing against it, as they believed they had been wrongly graded, often to a lower grade, and consequently, divisions and disharmony among staff resulted, with nurses complaining that the grading system was flawed, since some nurses were put on a higher grade than their colleagues who were doing the same job (O'Dowd, 2008). This led to industrial unrest, as some individuals decided to go on strike.
I believe inaccurate pay grades were further compounded by intervening pay freezes, which meant nurses did not receive a pay rise from the government, sometimes for several years and, consequently, nurses had to use other means to supplement their wages. When I started my training in the 1970s, to survive, nurses on lower grades of pay (including me) often relied on agency and bank work. Today, nurses on lower grades of pay are still reliant on agency and bank work to survive, especially if they are the main breadwinner. Since this extra work necessitates working on days off, there is a direct impact on work-life balance, specifically the capacity for getting sufficient rest, and spending quality time with their families. This situation is even further compounded by the working of unpaid overtime - an unspoken expectation that relates to almost all nurses, and which is rarely compensated with additional pay.
Today, nurses' pay in England is set by Agenda for Change (AfC), a pay strategy with pay bands ranging from band 1 to 9 (plus variations in between, from band 8a to 8d). Initially, there were yearly incremental pay increases (spine points) that continued until the individual reached the top of their pay scale. This did not acknowledge the individual's academic achievement with extra pay. In fact, pay was set at the same level regardless of academic achievement or status. Following the implementation of the 2018 NHS pay deal, pay progression for those under AfC terms has changed from the historic spine points to a system based on years of experience at that band (NHS Employers, 2022). Although this is a positive acknowledgment, there remains a question of whether it will make a significant difference to nurses' pay, specifically, for those on the lower pay spectrum.
It is evident that the government plays a significant role in managing the NHS, and although ministers purport to understand and appreciate the inherent struggles that are faced by nurses in their quest to deliver optimal care to their patients, I remain sceptical – perhaps because I believe that understanding and appreciation would necessitate an acute insight into caring and placing the same level of value and importance on the public's health as they do their own. To obtain a true insight, they would need to ‘walk in our shoes’, so to speak. But why would they want to? After all, for them, money is not a problem, and neither is access to care, since most, if not all, have the choice of accessing the private sector for their healthcare needs.
However, despite my scepticism, I firmly believe that when it comes to making decisions about pay, the government should acknowledge that, in making a request for a pay increase, nurses are not remiss in the fact that the NHS is one of the largest employers and that managing healthcare is a challenging task that is made more so because one cannot predict when people will get ill, or because people are living longer there is in turn an immense impact on funding. However, if we are to believe that good health is a person's most valued asset and that in delivering a health service that is targeted to meeting the individual's health needs (Anderson, 2022), nurses play a crucial role, then when making a pay decision, a credible offer must be a priority.
I believe the recent strike action speaks for itself. As a result of the longstanding dissatisfaction regarding nurses' historical pay awards, and the added impact of the recent COVID-19 pandemic, rising inflation, and consequently, the rising cost of living crisis, nurses can no longer turn a blind eye to the fact that they are struggling to make a decent living, for themselves, and their families – they deserve a fair salary and are now prepared to fight for it.
In comparison with nurses' pay in the 1970s, arguably, pay today is better than it used to be. However, due to decades of below-inflation pay awards, it is fair to say that nurses' pay has not kept pace with inflation, and is now so far behind where it should be, that it is almost impossible to make significant reparations. Nevertheless, if the government truly values nurses, then I believe ministers should put their money where their mouth is. Although they have proposed a 5% pay offer, a more credible offer would be one that comprises double-digits. I believe a credible pay offer would be conducive to making inroads into ongoing problems such as recruitment and retention and the current ensuing staff shortages, and would, once again, place the focus on making nursing a meaningful profession that is attractive to potential entrants. A credible pay offer could go a long way toward ensuring patients receive the care they deserve, and since nurses are integral to the delivery of this care, they are paid a salary that is reflective of their skills, status and worth (Patterson, 2012).