Nursing and midwifery - Listening Project: You shared, we listened

3. Focus groups and survey with nursing and midwifery staff

Phase two of the Listening Project consisted of a series of focus groups with nursing and midwifery staff to learn in more depth about their experiences and perceptions of their work situation. In total 462 members of staff participated in the in-person focus groups and 122 in the national virtual focus groups. A further 607 completed the online free text survey which consisted of similar open questions as asked in the focus groups.

The focus groups were structured around the following open questions:

• What is it like being a nurse or a midwife?
• What is good about being a nurse or midwife?
• What is not good about being a nurse or midwife?
• Why do people stay in the role?
• What would you suggest on how to improve any of the issues affecting nurses/midwives/yourself?

3.1 Demographic information

Of the 462 who participated in the in-person focus groups 393 (86%) were nurses or affiliated to nursing and 66 (14%) were midwives or affiliated to midwifery. This included 14 health visitors and 33 non-registered staff and students. Three people participated in a supporting role to the staff.

Of the 607 survey responses, 474 (78%) were nurses or affiliated to nursing and 128 (21%) were midwives or affiliated with midwifery. This included 63 responses from students and non-registered staff. The majority of the respondents had been qualified for at least 10 years and most people worked in bands 5 to 7.

Tables 1 to 4 show the number of qualified nurses and midwives by banding and years qualified. However, data was not collected from all staff and therefore some is missing.

The survey and focus groups generated a large amount of data and feedback which was categorised under two headings: Feelings towards the job and Workplace and wider system factors. The latter has been guided by the Pulse Poll findings and the conceptual checklist on retention by Buchan and Catton (2018, 2023).

3.2 Feelings towards the job

Overall, the most consistent theme that was identified in the responses from staff who attended the focus groups and those who completed the survey is the love that most staff have for caring for patients. A number of terms including “rewarding”, “it’s my identity” and “it’s a privilege to care for people” were frequently used by midwifery and nursing staff across health boards, settings and bandings to describe how they connected to their work and roles

“Yes, it's very rewarding and you feel valued when your patients come back to you and say thank you very much for the care that you've given me.” (deputy charge nurse, 3-10 years qualified)

However, this was often then balanced by frustration, reflecting that the role is “challenging” and particularly by those with many working years “not as good as it used to be”. In contrast some newly qualified staff commented that after a few initial challenging and frustrating months their confidence was growing.

Part of the frustration stemmed from the perceived workplace barriers that impacted on their ability to be able to be in post and deliver good quality care. In many instances this was linked to not having sufficient time to spend with patients and to not feeling listened to when raising this with managers. For those in managerial positions workplace barriers also impacted on not having enough time to support their team.

“If people can do their job the staff morale would be so much better and people would come to their work, not phoning in sick, not feeling burnt out. That is the bottom line, people actually love to care for their patients as long as that’s what they are passionate about.” (staff nurse 10-20 years qualified)

“We love our job, we just don’t like the conditions we are in.” (advanced practice advisor, 10-20 years qualified)

Many commented on the strain these conditions had on them, which varied in severity depending how tolerable the challenges to their daily work were felt. In the survey more midwives than nurses commented on feeling exhausted and burned out.

“Most of my colleagues are very fragile and cry on a regular basis. The level of stress we are working in is not sustainable.” (health visitor, 10-20 years qualified)

“Not having enough time causes increased frustration and stress. It makes me question my abilities and if it's enough”. (community nurse, 20+ years qualified)

Another frequently mentioned issue affecting work-life balance was the difficulty of letting go of work when off-duty and at home. Whilst this was particularly highlighted by more recently qualified staff, lone workers and those being moved to other wards, it was an issue across the participants and linked to the emotional nature of the work of looking after patients and the competing demands.

“I worry that I forgot to do something, and it will cause harm.” (nurse, 20+ years qualified)

Specific targeted wellbeing initiatives such as yoga were perceived as helpful by some, but many felt that these were tokenistic gestures that ultimately do not address the root cause of poor wellbeing. It was clear that staff want to be able to manage their own wellbeing within their everyday working environment, sometimes with support in place. However, they do not appreciate self-care initiatives without measures to simultaneously address the challenging working environment.

“People talk about resilience all the time… but you can be the most resilient person in the world, but everyone has a breaking point.” (specialist nurse, 20+ years qualified)

3.3 Workplace and wider system factors

3.3.1 Manageable workload

Many reported that their job had evolved and no longer resembled the job they applied to do. This was particularly the case for those working in nursing. Many staff appreciated the opportunity to develop skills in different areas and the chance to upskill. However, shortages in other job families were having a knock-on impact on the range of tasks and responsibilities that now fall to them regardless of having relevant experience. For example, nurses reported that they carry out tasks on behalf of Allied Health Professionals, and staff in managerial positions reported that they carry out recruitment tasks as that function has been delegated from HR teams.

“We need to document what patients have eaten etc. but if I haven’t seen what they ate how can I complete it…. It’s not a nurse’s job, but it is also our responsibility. We are also responsible for Care and Comfort plans where you note how often you want skin checks etc, but you need to help the nursing assistant, so it takes a lot of time”.

(staff nurse, 3-10 years qualified).

Feelings of being undervalued were particularly present when tasks from a member of staff working at a more senior level were delegated without recognition.

Participants in more rural settings who perceived their responsibilities already to be wide ranging due to the locality also noticed an increase in tasks over time.

“It’s very different to nursing in other areas, we do a lot more on the ground that nurses on the mainland wards do…You don’t expect to be security, admin, etc. A lot of things are now our responsibility that take away from patient care.” (nurse, 10-20 years qualified)

Furthermore, many Band 5 nurses and Band 6 midwives commented on the increase in patient numbers that impacted on their workload. For example, participants reported that the pressures within the acute wards have increased due to the number of additional beds, often in inappropriate spaces (e.g. a fifth bed in a four-bed bay, a bed in a supplies cupboard) which give no privacy to patients and negatively impact on the quality of care staff feel they are able to deliver.

A number of staff felt that paperwork is seen as being more important than direct patient care. Higher bed occupancy rates and caseloads have led to more data inputting and documentation and therefore decreased the time available to spend with patients. In some health boards, respondents said that although accurate record keeping and documentation is a critical part of the job, this has been taken to extreme lengths with a culture of “if you don’t write it down, it didn’t happen”. A related issue was the amount and repetitiveness of this paperwork, which, according to many, could be streamlined to save time.

“Our paperwork for every patient is about 70 pages, such as risk assessments etc.” (senior charge nurse, 20+ years qualified)

“The amount of writing and documentation we have to complete has increased, which includes lots of duplication”. (health visitor, 20+ years qualified)

The increase in the number of patients requiring care was attributed by staff to a series of factors, such as pressures within primary care, reduced third sector support, increased referrals, lack of availability of social care services, and more chronic and complex illness and social factors. It was also noted that expectations from the public had increased both in terms of the speed, quality and breadth of care they expect. The high expectations have led to an increase in verbal and physical abuse received by midwifery and nursing staff.

Many participants in higher AfC Bands and in managerial positions commented on the unrealistic expectation of delivering the same service without more resources.

“We aren’t giving our nurses the time to spend and give the level of care they want to give. I see the daily impact on the Band 5s, they are frustrated, they can’t answer buzzers, falls alarms etc. it’s all the knock-on effects, and the lack of job satisfaction when you leave is higher.” (senior charge nurse, 20+ years qualified)

There was a marked contrast in the experiences of hospital-based staff versus community-based staff with several community-based staff reporting that they left roles working within hospital wards because of the working pressures and/or not being listened to when they raised concerns about patient safety. However, increases in caseload and administrative tasks were equally mentioned by community-based staff, especially by health visitors or in rural areas when staff needed to cover larger geographical areas. As a result, community-based staff across health boards reported to work extra hours and miss breaks, because they struggled to manage their workload in the time given.

3.3.2 Safe staffing levels

Mention of staffing levels were consistently linked with the change in workload, and with an increase in transferring nursing staff between wards as well as asking community midwives to cover shifts in hospital wards. Ward based staff felt that managers were under pressure to secure staff to work in the ward, even if they came without the right skills or experience. This was perceived as being at the expense of staff wellbeing, patient care and clinical judgment. A number of staff commented on the apparent misconception that a nurse or midwife can safely work in any setting without accounting for the knowledge and skills required.

“Community and hospital are very different kind of jobs in midwifery but seen as under one umbrella.” (midwife, 3-10 years qualified)

“We are bad for looking at numbers but not the complexities of the patients. Which adds stress, so you may be safely staffed but have multiple high risks patients, which then goes back to the fear of completing your notes, to protect your registration. But then you are rushing them to look after patients. Numbers take priority” (midwife, 10-20 years qualified).

Although moving staff to other wards to cover shortages is not new, there was a sense that use of this has increased considerably leading to destabilisation of teams and increased distress amongst staff, regardless of their years of experience. The root cause of this stress amongst staff is the feeling of being unsafe in their practice when they are moved to a ward area they are not trained for and that this can impact on patient safety.

“It lowers morale being moved to other sites across the hospital where I don’t have the relevant experience to be put in that situation.” (nurse, 3-10 years qualified)

“When staff are moved, it’s not creating a safe environment, on paper it looks safe but it’s not. The NMC says you should be working within your skills, but when you say that they threaten you with NMC registration, ‘you’re a registered nurse’” (nurse, 20+ years qualified)

As a way of managing this situation an example was given of teams scheduling less people on the rota to prevent being moved. Although this had the benefit of avoiding staff moving, it was far from ideal as staff were then required to often work alone and struggled to take breaks.

As a more positive example, one team gave an example of managers asking staff to list the skills and training they had and areas they felt comfortable to work in so that any staff moves could be more targeted. Staff reported that this worked well and helped allay their concerns.

Many participants mentioned the value of having a good team that works well together, are supportive of each other and help each other. Camaraderie and peer support from the team were perceived as a coping mechanism to manage the pressure and increase enjoyment in the working environment.

However, several midwives shared concerns that the introduction of rotational contracts had impacted on creating stable teams.

“Staff are rotated far too often and there is a severe lack of teamwork because we all get moved so much. we don’t know our colleagues like we used to”. (senior charge nurse, 10-20 years qualified)

While many participants agreed that more staff would improve the situation, they also pointed to the importance of retaining existing staff by improving the working environment and conditions. Midwives felt the same pressures around staffing with many areas feeling that they were short staffed. One reason given for this was an increase in the medical complexity and high-risk pregnancies of the women they care for, as well as an increase in the economic and social challenges faced by many women. Staff reported that antenatal appointments used to last 15 minutes but now require a minimum of half an hour due to the complexity of the women and number of issues to discuss.

“We aren’t just midwife anymore, we are social work, friend, bereavement councillor, child protection etc.” (midwife, 10-20 years qualified)

3.3.3 Working conditions and environment

Both focus group participants and survey respondents commented on aspects of their working conditions and environment and how these impacted on them and on their work.

• Flexibility

When discussing work-life balance, it became clear that despite having a flexible working policy within NHS Scotland, implementation of the policy is inconsistent within and between health boards and is at the discretion of local managers. This meant that if a midwife or nurse wanted to work part-time due to, for example, changing life circumstances or personal aspirations, this was not necessarily granted by management. The challenge of balancing the costs and opening hours of childcare facilities with working hours was highlighted, especially in rural areas with limited childcare facilities.

Participants shared examples of feeling discriminated against for working part time, both in terms of selection for training and promotion, with staff being successful in gaining promotion but subsequently being told they could only take up post if they worked full time. As a result, some participants had left to join the Staff Bank so that they could have the flexibility of the working pattern they needed for their personal circumstances, and many knew of colleagues who had left the profession because of barriers to flexible working.

Participants expressed mixed views on 12-hour shifts. Younger staff particularly tended to favour longer shifts with working a shorter week and more time off, though they confirmed being exhausted by the end of the shift. Others, often older staff, found it increasingly hard to manage longer shifts and felt that they accelerate the feeling of burnout. Many managers highlighted that trying to schedule training in a 12-hour shift was very difficult.

Shifts being set hours can be difficult, especially for staff with childcare responsibilities who depend on nursery opening hours with staff reporting a lack of flexibility from managers around requesting a later start time. The feedback and issues around working, and shift patterns were ultimately about staff being allowed to work flexibly and matching their work with their personal circumstances.

From a managerial perspective the challenges of flexible working were highlighted, particularly with implementing the policy fairly across the team within the resources they have. For example:

“The service needs are changing and it’s about getting managers to align with work life balance and flexible working policies being applied equally and not just to those with children. Work life balance just isn’t there now.” (senior charge nurse, 10-20 years qualified)

• Productive working relationships

As mentioned earlier, one of the main positives highlighted by many staff during the Listening Project was working within a supportive team. Having peer support from colleagues can provide informal support, and especially on more challenging days.

“I am part of a lovely, supportive and hard-working team. If it was not for the support of my colleagues, team leader and manager my job and stress levels would be much higher.” (community nurse, 3-10 years qualified)

However, that support is not always available in every team and staff reported that it can be difficult to challenge bad behaviour and negativity or when sub-optimal levels of care are observed. This lack of psychological safety to express concerns can directly affect staff and their desire to continue working within a team and can also lead to higher sickness rates. Many were unaware of who to go to if they wanted to raise a concern and there was a feeling that “bad behaviour” was not challenged, with managers unwilling or unable to have difficult conversations.

Staff also reported that - in more severe cases - they do not feel safe to utilise the whistleblowing policy. Their perception (in some cases based on previous experience) was that they will be moved to a “worse” area and that nothing will change or that the situation will get worse due to the pre-existing relationships between managers and staff which have been described as cliquey in some cases.

“It’s hard for people to bring things up – I said a comment and it went back to my Head of Department. No one feels safe to talk out or whistle blow.” (midwife, 3-10 years qualified)

“the person who raises the concern goes through the mill”. (senior nurse manager, 20+ years qualified)

• Integrated IT systems

A common frustration was working with multiple unintegrated IT systems that were not always straightforward to use and required duplicating data inputting. For example, one participant counted 10 different systems each with its own log in.

The challenging and time-consuming number of IT systems that many participating staff dealt with seemed most keenly felt in community settings, particularly when hospital ward systems were not communicating with GP systems or community-based systems which can lead to a delay in the community staff following up treatment.

In some examples the community-based staff had been late in delivering follow up care because of the delay in updating the system. In another case, hospital staff were unaware that a child admitted to their ward was on the child protection register because they did not have access to the community systems and were therefore unable to alert community-based staff following admission. IT systems being unable to communicate with partner organisations, such as social work added further challenges including staff safety issues with community-based staff unaware that a patient may have a history of violence when they are visiting the patient at home.

“We are being threatened with a new system in the community, there’s different systems for different parts and depends on the GP practices etc. I have three systems to input information for diabetic reviews and then I have to write it all out again in a fourth system that repeats everything.” (staff nurse, less than one year qualified)

3.3.4 Responsive management and decision making

Support and visibility of direct managers and above appeared to vary considerably across health board areas and can directly impact on staff. It was clear that there was not one view of good leadership as it depended on the setting and circumstances and managers’ ability to adapt to these. Good leadership was also seen as a personal attribute with some people just being good at it. As one nurse said:

“I feel completely supported, at times there will be sickness and she will come so you’re not alone. She wants us working safely and it feels like she has your back”. (Primary care nurse, 10-20 years qualified)

Participants in some health boards gave examples of good, supportive leadership where managers were visible, gave hands on support when circumstances were challenging and involved staff in decision making. A positive example was given within midwifery where a new management team was appointed and took time to work on the ward to understand the role. Discovering that workload was higher than expected at specific times, the managers revised the assumptions used in the workload tool that. This was appreciated by staff who confirmed being part of the changes and their suggestions had been listened to and acted upon. In return both nurses and midwives who felt supported by their managers seemed more understanding of the pressures put on their managers.

“It’s about compassion around the conversations you have. Sometimes it can be frayed and can get heated. It’s about having that professional conversation without it becoming challenging. You can still be nice about it. Despite the challenges you would have a better culture. The art of conversation, listening with fascination, compassionate conversation. Civility saves lives.” (midwifery manager, 20+ years qualified)

By contrast, many staff reported a disconnect between their immediate team and more senior management within the health board which left them feeling unsupported or as “a number on a spreadsheet”. A lack of visibility and engagement led to questioning senior managers decisions and their lack of understanding of what goes on at the front line. These comments were made across different health board areas, by staff with managerial and non-managerial responsibilities, and by staff whose managers were based in the same corridor as well as geographically far removed.

There was a sense amongst a number of staff that underlying all of this was a desire from senior health board staff to present a more positive picture to the Scottish Government than may actually be the case. This was also reflected in feedback from staff around completing audits for the Scottish Government where they would be “told” what the result of the audit would be ahead of actually completing it.

“You feel out of control because all these decisions are made but you’re wondering who made them and where it comes from. It might look good on paper but it doesn’t work in reality, they have no clue how it actually works.” (senior charge nurse, 20+ years qualified)

Also, many staff reported that they were confused by the often complex, multi-layered management structure within their area and led people to question what so many managers did with their time and how they advocated for their staff.

• Decision making

Empowering staff with autonomy to exercise their professional judgment and have some control over their daily work was perceived as good leadership. Some staff in senior roles acknowledged that sometimes they did not have the capacity to support staff by discussing or explaining clinical decisions.

While this was experienced by some as part of their role, especially by those doing lone working, many midwifery and nursing staff reported having little opportunity to be involved in decision making processes or to have their suggestions acted upon.

Top-down communication, hierarchical leadership, or micromanagement were perceived as barriers to collaborative approaches to decision making, including by staff in senior management roles.

“The more detached we are becoming from having that autonomy, the bigger impact it has on morale, because we know what our staff do, but we get pressure from above. I’m sandwiched from pressure below and above.” (senior charge nurse, 10-20 years qualified)

• Supporting students

A number of discussions centred around the importance of having good learning environments for students. However, the lack of capacity to effectively manage and support students on placement was frequently mentioned by existing midwives and nurses, particularly on wards where, at times, newly qualified staff can be the most qualified on wards due to staffing issues.

“We’re trying to figure out the work ourselves and then you have all this pressure to teach a student and try and guide them on the right path, but how can you physically do that when you’re understaffed and overworked? It’s not fair on anybody”. (staff nurse, less than 1 year qualified)

Across health boards staff commented on some students appearing under prepared for the role or being mainly interested in the more challenging, technical aspects of the role.

“It is hard when you have a student that needs a bit more support. Nursing is hierarchical. Society has changed, cultures have changed, but people seem to think they can come in and not be directed and told what to do”. (senior nurse, 20+ years qualified)

Furthermore, newly qualified staff said that they are now being taught skills that previously were not done by nurses. This means that they can be leaving university being able to complete certain skills some colleagues may not be able to do. As a result, some nursing and midwifery staff were unsure how best to support and interact with students.

The transition from student to newly qualified nurse was perceived as challenging and while there is a programme in place (Flying Start), in reality, newly qualified staff can find themselves as the most senior member of staff or in charge of a ward within a matter of weeks. An example was given that in one health board, all of their newly qualified staff left within the first year. So, the following year they took a different approach, ensuring dedicated support for the newly qualified staff to ease the transition which included a number of weeks working supernumerary. This was noted to be far more successful in retaining the newly qualified staff.

3.3.5 Career opportunities and access to training

For both nurses and midwives, opportunities for professional development as well as practice development and (mandatory) training were perceived as important and rewarding elements of their jobs. Several staff with more working years spoke enthusiastically about their variety of roles and multiple careers.

“Well, I absolutely love it, and I've been in the NHS for 30 years and I've had various different roles, so I'm a general nurse and a registered midwife. And I've not lost my enthusiasm, although it's been tested at times” (midwife, qualified 20+ years)

“We don’t sell the variety, people leave because they have burn out but aren’t told about other areas.” (senior nurse manager, 10-20 years qualified)

While many staff were positive about professional development, it was clear that this was not always available consistently or universally. For example, several midwives commented on the lack of consistency in promoted roles available and clear pathways to move into these roles. While some said that they did not want to progress, a number of staff had moved to other roles, such as Family Nurse Practitioner or Health Visitor in order to progress.

Others, in more rural areas also commented on less opportunities for career development and at times felt they had stagnated.

“I am stuck in my job, there is nowhere else for me to go in this health board. I’d need to move to a bigger hospital, but that means moving house.” (nurse, qualified 20+ years)

It was also noted that boards and settings varied in providing protected study time. While community-based staff commented on having study time, others, particularly those working in hospital-settings, commented that the handover time on a 12-hour shift is very tight and it is near impossible to be released for training. This resulted in catching up on mandatory training in their own time. In turn this could lead to resentment, especially when it was felt that their managers took their effort for granted. Several managers also commented on the lack of capacity to release staff for training and the impact this had on the provided care.

“Adult nursing is changing, and we see more mental health concerns coming through than ever before. But we aren’t educating staff in how to care for patients. We aren’t allowing staff to develop and train. We just don’t have enough people to release newly qualified staff. We have a lot coming in, but we don’t have enough experienced nurses to release them.” (senior charge nurse, 20+ years qualified)

Opinions on online learning were mixed. With some, especially in rural areas noting the increased opportunities through online learning or Open University (OU), others found it more challenging to learn online with one person commenting:

“it is difficult after work, I just can’t face it”. (nurse, 20+ years qualified)

A separate issue was that there appeared to be little incentive for promotion with staff at higher bands reporting that they now earn less than they did when working as Band 5 because of the pay enhancements such as shift and weekend working offered.

3.3.6 Pay and incentives

Though it was known that the issue of pay was beyond the scope of the Taskforce, inevitably the topic was brought up across the focus groups and in the survey. Also the topic of perks was mentioned by participants with different bands showing the impact this can have on feeling valued and creating commitment to the organisation. Some gave negative examples of the lack of perks, such as receiving no acknowledgement for 25 years of service or cutting the free lunch on Christmas day. Others showed its positive impact.

“With the newly qualified members of staff, we gave them a little bag of different things. And you know, they were absolutely delighted, and it's like simple wee things that you do. It's not rocket science, is it? It’s just feeling appreciated.” (midwife, qualified 20+ years)

3.4 Midwifery

Overall midwives who attended the focus groups or responded to the free text survey tended to raise similar issues to those highlighted above. The reason for this overlap is probably because many of the issues raised relate to wider system, societal or leadership challenges that impact on both professions. Staff reported that they enjoy their role with similar comments about the job being “rewarding” and feeling “privileged” caring for women and their families.

Staff reported similar pressures around staffing with many areas feeling that they were short staffed. One reason given for this was an increase in the medical complexity and high-risk pregnancies of the women they care for, as well as an increase in the complexity of living and working arrangements social challenges faced by many women. Staff reported that antenatal appointments used to last 15 minutes but now require a minimum of half an hour due to the complexity of the women and number of issues to discuss. This can make it harder to manage workload in the allotted time.

Some staff mentioned that the skill mix balance often does not feel right, and some teams can be heavily weighted to less experienced staff which puts increased pressure on more experienced staff. This can lead to the more experienced staff feeling unable to take breaks as they feel unable to leave less experienced staff to care for increasingly medically complex pregnancies. There was a feeling amongst some staff that rotational contracts are contributing to the unbalanced skill balance within teams. This can see the staffing within teams changing regularly with a continuous inflow of inexperienced midwives.

Loyalty to teams came across strongly in many areas which had the benefit of more willingness amongst staff to cover shifts. However, many staff raised the challenges of working on call and the practical impact this has with staff effectively working for 24 hours. Some also mentioned an “us and them” atmosphere between community and core/hospital midwives. A number of staff said there was a “blame” culture in midwifery with managers unwilling to support staff or provide support when adverse events occur or when the ward is understaffed. However, there were also positive examples of good practice in leadership.

Staff talked positively about clinical supervision and highlighted that this has been embedded into practice. However, an issue raised by some staff was around the information around career progression not being clear. There is a lack of consistency in promoted roles available across NHS Scotland and clear pathways to move into these roles. A number of staff leave midwifery to move to other roles, such as Family Nurse Practitioner as it is a higher banding but with a reduced caseload.

In Appendix 2 is a diagram with the perceived barriers and their impact on staff’s wellbeing.