Editorial: A workforce in jeopardy?

This year we marked the centenary of the end of the Great War. I was privileged to attend a screening of ‘They Shall Not Grow Old’, a film directed by Peter Jackson, in large part in honour of his grandfather who died in the conflict. Using contemporary computer-assisted cinematographic techniques, coupled with the extraordinary skills of expert lip-readers and the insightful oral histories of survivors, Jackson brought alive 100-year-old film footage and provided an accessible window into the thoughts and experiences of those who served in and survived the war, and the battle of the Somme in particular.

As I watched the film I was struck by particular aspects of the account. The first was the camaraderie of the desperately young British conscripts. Conscription was easy and appealing, and boys as young as 15 and 16 were encouraged and enabled to lie about their age so they could sign up to ‘fight for their country’. The transition from training on British soil to the trenches on the Western Front was unquestionably harrowing, and I was struck by the use of humour in such circumstances. In the Question and Answer session with the film director that followed the screening, Jackson argued that when you are at breaking point, humour is all you have left.

I was also struck by the explicit articulation of the absence of any clarity of strategic purpose. There was no clear understanding amongst the soldiers as to why they were fighting the German soldiers, and -- perhaps paradoxically -- the British and German soldiers voiced a strong sense of mutual respect for one another.

This was exemplified by the medical teams where the German and British teams worked side by side helping casualties of either side as best they could in dire conditions. In Jackson’s eyes the lack of clarity of purpose and the collaborative working of the medical teams highlighted ‘the stupidity of war’.

Finally, I was struck by the overwhelming sense of anticlimax when the war was declared over. The soldiers felt redundant. Soldiering was their identity, and for the majority the only job they had ever had. And while the soldiers grieved their loss of identity, those back home grieved the loss of their loved ones. The soldiers who survived felt resented because they had been spared when others had not. No one talked about the war. The transition from soldier, a ‘brother in arms’, to a ‘nobody’ was difficult and painful.

The implications and the impact of this film are, in my mind, profound. And for me, the film offered an opportunity to reflect on the contemporary state of nursing and the papers in this edition of JRN through a different lens.

But before I go into that, this edition starts with a Guest Editorial that examines the current trend in primary care medicine to ‘socially prescribe’ and think outside of the traditional medical box of tricks. Kenkre and Howarth offer a considered critique of this development through a nursing lens.

This edition in the main offers a range of papers on the nursing workforce -- a workforce that is arguably in a state of transition, as well as, if not paradoxically, in crisis. I have borrowed from the title of the first paper for the title of my editorial. A workforce in jeopardy seems to sum up the current mood in nursing, in the UK at least. Certainly our lives are not in jeopardy as the First World War conscripts were, but it would appear in part that our livelihoods are, as is the sustainability of the services we provide. The rhetoric of safe and effective care can only be realised through a safe and effective workforce, and safe and effective workforces don’t just happen. They need to be systematically planned and reviewed in the light of demographic, epidemiological, technological and knowledge developments. They need to have standards for training and practice which also need to be reviewed as a matter of routine, and the workforce must be properly resourced from student to retirement in terms of remuneration as well as life-long learning needs and requirements. Without all of these elements in place, coupled with robust balances and checks, safe and effective care needs to go to the top of the risk register of every health and social care policymaking and service provider organisation.

The first paper in this edition sets the scene. Piercy et al. raise concerns about the sustainability and future development of the specialist human immunodeficiency virus (HIV) nursing workforce. Through a mixed-methods approach they identify the challenges confronting this workforce in England and call for a strategic approach to workforce development to ensure the quality of care for people with HIV. They argue that a strategic approach is required in order to ensure systematic role expansion and development to meet patient needs, to counter the vagaries of service commissioning that inadvertently jeopardise established career pathways, and to address the absence of advanced-level specialist training programmes. Reviewed by a pioneer of nursing development within the field, Miles advises that this account of the current status of the speciality is a disheartening read. He argues for a strategic approach to impact: it must be a collaboration between professional leaders in the field, service commissioners and providers.

We surely can learn from the loss of identity and the feelings of redundancy articulated by the soldiers at the end of the war and see the potential for this to happen in nursing when examples of cracks in the system are laid bare, as they are in this paper. Yet there is evidence elsewhere that indicates that the economic arguments for addressing these concerns are compelling (Watson, 2015). Nevertheless, a strategic approach within an at best fragmented and at worst broken system is extremely challenging. The public and professional challenges to the architects of such a system must therefore be strategic, coherent and relentless whilst simultaneously fully engaged with the needs and aspirations of the populations served.

Recruitment and retention challenges are widely recognised as contributing to the jeopardy of the nursing workforce. Acknowledging that since 2017 more nurses have left than joined the UK nursing register, Halder discusses the significance of nurses’ job satisfaction on retention figures. From his review of the literature he argues that nurses' job satisfaction is related to pay, respect, security, workload, recognition, responsibility, environment, autonomy, personal growth, administrative bureaucracy and caseload. He suggests that an investment in and the promotion of what he describes as ‘organisational compassion’ may contribute to improving nurses' job satisfaction, and in turn, retention. The review of this paper is by Radford, a nurse and policymaker with a lead responsibility for identifying and addressing the challenges of workforce retention in England.

Despite these challenges, there are some wonderful examples of initiatives to improve the sense of worth and job satisfaction of nurses and ultimately the quality of the care they provide. The strong sense of professional purpose and the ensuing camaraderie and perhaps good humour of those leading the charge to create the conditions where research and innovation flourish in nursing are, in turn, enabling nurses to flourish and feel satisfied and fulfilled in their roles. The next two papers provide such examples.

In the first of these two papers, Bramley and colleagues describe the implementation and preliminary evaluation of a hospital-based initiative in England designed to develop the foundational clinical and academic skills of frontline junior clinical staff. As MacArthur, a leader in clinical academic role development, notes in her review, this paper is a welcome addition to the literature in the field, which hitherto has focused on more senior positions (MacArthur, 2015). Essentially this is a chief nurse’s talent-management initiative to retain nurses with potential and prepare them for clinical academic development opportunities and leadership positions. It includes a bespoke programme designed to develop capacity and capability in innovation, leadership, improvement science and change management. Participants completed an improvement project and were supported through clinical and academic mentorship by doctorally prepared nurses. Importantly, participant capacity was released at the rate of 0.2 whole-time equivalents per participant through the reallocation of vacancy funding to enable them to undertake and complete the programme.

The evaluation of the first cohort of six participants presented in this paper demonstrated evidence of their professional development. Case studies of completed projects showed demonstrable impact on patient experience, outcomes and costs. Wider dissemination activities increased the profile of the initiative, the participants and their case studies. A longer-term impact evaluation is planned.

The second paper in this theme, by Fullam et al., describes the evaluation of an initiative to increase the research capacity and capability of nurses and midwives across a region in Ireland. A previous evaluation of clinical nurses and midwives, in particular those in specialised and advanced positions, demonstrated a dearth of ‘research engagement and output’. This was in part attributed to a lack of support and research skills development within this workforce, therefore a bespoke research capacity building initiative was introduced. A document analysis was conducted to determine the research processes and outputs and the extent to which the initiative contributed to research capacity development over a 3-year period. With no baseline measures, the limitations of this evaluation are acknowledged; nevertheless, important key points for policy, practice, development and research are identified at this stage in a process designed to normalise research activity within the nursing and midwifery professions. Perhaps the most telling point was the lack of consistent backfill for those who participated in the initiative, noted by the authors as an important variable over which they had no control. With the current levels of work intensification in the name of efficiency, initiatives like this have the potential to be counter-productive by adding to nurses’ stress levels, impacting negatively on their sense of self-worth and job satisfaction. If there is a need to build capacity within a workforce, there must be a commitment to release capacity for that building to take place. The normalisation of continuing professional development (CPD) initiatives where capacity is not identified and meaningfully addressed, that places ever increasing and unrealistic demands on nurses, should not go unchallenged.

In her review of this paper Topping helpfully locates its contribution within an international context and offers an informed perspective on what needs to happen next.

The penultimate paper in this edition, by Budak and Özer, considers and compares the clinical leadership skills of nurses and physicians in a hospital in Turkey, arguing the importance of clinicians in leadership and of shared leadership in context, as opposed to assumed leadership associated with job role or status. Just as the German and British medics stood side by side in the Great War attending to the needs of the casualties from both sides, when working effectively, nurses, physicians and other clinical staff stand side by side and share leadership responsibilities. The review of this paper is by Stanley, a recognised voice in clinical leadership research and development.

The final paper in this edition, by McGarry et al., is an ethnographic study illuminating the contribution of perioperative nurses. Through the analysis of observation and interview data, two themes were identified: ‘maintaining momentum’ and ‘accounting for safety’ were recognised as a source of tension, created by developments over which they had little or no control. Nevertheless, finding the balance in caring for patients in this environment was identified as a source of job satisfaction despite this tension adding to the emotional labour inherent within these ‘hidden’ roles. The review of this paper by Morrison concludes that this paper makes a useful contribution to the literature by providing an insider view of nursing within the perioperative setting.

The power of the insider view of the soldiers in Jackson's film was palpable. I don’t think we can underestimate the power of the insider view of nursing, nor do I think it is a power we as professionals have fully capitalised on to date. In this edition we have an insider view of the role of the perioperative nurse and the challenges facing the sustainability of HIV specialist nurses. This is precisely the sort of professional knowledge that must be mobilised and included in workforce planning as well as in service development and commissioning decision making. Furthermore it is incumbent on clinical and professional leaders to purposefully and systematically use nursing knowledge, highlighting the complexity and the impact of nursing practice, in policy and in particular workforce planning, decision making. Equally they must recognise their stake and exercise their influence to ensure that gaps in nursing knowledge are identified and addressed. Is it not your command of your professional knowledge that entitles you to a professional leadership position, and effects your impact?

The normalising of the development of nursing capacity and capability to use nursing knowledge and research methods in the development of their practice, to demonstrate improvements in practice and to develop new knowledge to inform practice make this feel more like a reality within our grasp than an aspiration. We might be in jeopardy but on the ground there are still inspirational nurses putting up a damn good fight. I normally don’t like and avoid war analogies but in this context it feels wholly appropriate. Let’s clarify our collective purpose (and revisit this as a matter of routine), mobilise and grow our knowledge, engage our troops, renormalise capacity and capability building as a professional right, not just a responsibility, fight the battles with each other and other stakeholders, in order to improve individual and societal health and well-being. With good humour and integrity, together let’s take nursing, and by definition safe and effective care, out of jeopardy and win this war.