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

5. The Listening Project in a wider context

The purpose of the Listening Project was to engage and listen to current and future nursing and midwifery staff and academics, and to learn about their experiences that impact on both their wellbeing and their ability to work safely and effectively in the professions and to undertake the programmes of study required to enter these professions.

The outcomes of this Listening Project helped to shape the recommended actions of the Taskforce, which centred on enabling the creation of working and study environments that will ensure the nursing and midwifery professions in Scotland are attractive and rewarding career prospects.

The literature helped to illuminate the findings of the Listening Project by showing how the experiences of those who participated aligned with existing evidence. Furthermore, presenting concepts associated with this evidence enabled illustration of the complexity of how workplace and study factors can influence attraction and retention in the workforce.

5.1 The international context of nursing and midwifery

Many participating nurses, midwives in the Listening Project commented on the high workload and expectations from management and patients. Particularly those with more working years noted an increase in workload, higher pace, and increase in the number of patients. This in turn seems to lead to frustration and burnout amongst staff. Buchan and Catton (2023) point to a vicious circle of burnout leading to more staff absences which in turn leads to more pressure on the remaining staff. Students also commented on the high workload in practice and that this could result in missing learning opportunities because they were asked to help out. In turn nursing and midwifery academics noted an increased sense of anxiety among their students and attributed this to practice learning. They also highlighted concerns around their own risk of burnout, pointing to high workloads and challenges with recruiting staff to teach the future nurses and midwives, an issue also highlighted by the unions (RCM 2023, RCN 2022, 2023). The rising demand for care, which risks outpacing the supply of nurses and midwives in Scotland, is also a worldwide concern, including in other high income countries (HICs) (Kroezen et al., 2015; WHO, 2020, 2021; Buchan and Catton, 2023).

According to the WHO (2020, 2021a) several factors contribute to this situation in HICs, such as:

• Changing demographics with people living longer, and older age-groups making the highest demands on health and social care services.
  • In Scotland the 65+ years age group increased by 22.5% from 2011 to 2022, (NRS, 2023). Furthermore, from 2009 to 2023 there has been 20.6% reduction in birth rates per 1,000 women, but medical (including caesarean sections) complexities which require more highly specialised care have increased (PHS, 2023).
• The nursing and midwifery workforce is ‘aging’,
  • In Scotland 20.5% of nurses were aged 55 and over in 2023 and 18.7% of midwives (NES, 2024).
• Underinvestment in services and education has been an issue in many countries.

With midwives and nurses being key to universal health coverage and the United Nations’s Sustainable Development Goals, the urgency to act and improve the nursing and midwifery workforce is reflected in international strategies. The Global Strategic Directions for Nursing and Midwifery 2021-2025 strategy (WHO, 2021b) sets out directions for Education, Jobs, Leadership, and Service delivery to scale up the workforce required to meet increasing demand and improve retention. The strategic policy directions are:

1) Educating enough midwives and nurses with competencies to meet population health needs

2) Creating jobs, managing migration, and recruiting and retaining midwives and nurses where they are most needed

3) Strengthening midwifery and nursing leadership throughout health and academic systems

4) Ensuring midwives and nurses are supported, respected, protected, motivated and equipped to safely and optimally contribute in their service delivery settings.

In parallel there is an increase in national policies and strategies across the world, such as Canada’s Nursing Retention Toolkit Improving Working Lives Nurses (Health Canada, 2024), New Zealand’s Workforce Plan 2023/24 (Health New Zealand, 2023), and the recommended actions by the Nursing and Midwifery Taskforce in Scotland.

5.2 Different perspectives from the literature on retention

Looking at the wider literature shows that the issues identified through the Listening Project are also supported by both national and international evidence.

5.2.1 Positive and negative factors impacting retention

The Listening Project participants highlighted organisational factors that led to frustrations with their daily work, which could subsequently affect their wellbeing or the way they felt about their job. Participants often elaborated that the significance of these factors changed over time (e.g. needing flexible working when needing childcare or needing more support when transitioning from student to newly qualified) depending on their personal circumstances. Moreover, students commented on the high workload of midwives and nurses, particularly in acute settings, not matching the created expectations of the roles.

Through a systematic review of 34 studies Pressley and Garside (2023) identified that nurses stay in post if they experience job satisfaction (which refers to being satisfied with the work environment culture, and conditions) and are committed to the healthcare organisation (which refers to having positive professional relationships).

Also, they must have the personal ability to navigate the psychosocial and emotional dimensions of the job, meaning that they must be protected to manage stress and feel empowered to feel in control of the situation they face. Pressley and Garside (2023) identified factors that contribute to job satisfaction and organisational commitment and found that the weight of these factors is not fixed and vary depending on age and career stage (see table 1).

Table 1. Framework by Pressley and Garside (2023) on protective factors for retention

Job satisfaction: a) Environmental factors: organisational culture

• Conditions of work, Work environment, Safety climate, Workplace culture, Organizational support, Pressure management, Flexible working, Perceived
  development

Organizational commitment: b) Relational factors: professional dynamics

• Leadership, Teamwork, Trust, Organizational conflict, Job embeddedness, Social support, Belonging

c) Individual factors: psychosocial, emotional and professional cultures

• Stress, Morale distress/emotional labour, Emotional intelligence/personality, Burnout, Work–family conflict, Resilience, Autonomy, Job control, Empowerment, Professional value

Dall’Ora and colleagues (2020) conducted a systematic review on what caused burnout in nursing. Based on 91 studies, they concluded that patterns of adverse job characteristics, i.e. high workload, low staffing levels, long shifts, and low control are linked with burnout, with potentially severe consequences for staff and patients.

Also, as part of a wider study to assess midwives’ intention to stay or leave their employment in Scotland, Moncrieff and colleagues (2023) conducted a survey through which they found that the main reasons for intention to leave related directly to working life, with at the top insufficient staff, impact on mental health, burnout/emotional distress, high workload, and inability to provide quality care.

The 2023 Employment survey by the Royal College of Nursing (2023) presented a stark picture of the state of nursing in Scotland with almost half of respondents (46%) actively planning or thinking about leaving their jobs. However, it was noted that 59% would describe nursing as a rewarding career and 50% agreed with the statement ‘most days I am enthusiastic about my job’.

A report by the Royal College of Midwives on why midwives leave showed that the greatest reasons were because of staffing, workload and not having enough time to give women and their families high quality care (RCM, 2016).

The Nursing and Midwifery Council monitors through their annual survey the reasons why people leave the NMC register. Registration is a prerequisite to practising nursing or midwifery in the UK. In Scotland 33% (980) of the people who left in 2023 completed the survey with the top five reasons being retirement, followed by poor health, burnout, a change in personal circumstances, and lack of support from colleagues or senior members of staff (NMC, 2024).

Findings from studies looking at the experiences of midwifery and nursing students and newly qualified staff also overlapped with findings from the Listening project, especially in terms of the need for enhancing their experience through supportive and safe learning environments that include opportunities for clinical simulation, increasing their sense of connection and enhancing motivation and care.

For example, a systematic review looking at the impact of simulation on self-confidence of nursing students highlighted a reduction of anxiety and increased self-confidence (Labrague et al., 2019). Also, based on a series of interviews with newly qualified nurses in Scotland to investigate what might help newly qualified nurses stay, Ho et al. (2020) reported that the experience of transition shock can be influenced by the work environment in both positive and negative ways. This impact depends on the level of support available and the opportunities to form positive connections with colleagues, especially in busy and pressurised environments. Additionally, the extent to which the work environment affects home life also plays a role in the experience of transition shock. Through a review of the literature Bumby (2020) highlighted the importance of support (through a retention program/specialist, robust orientation, mentoring and tutoring, remediation as well as stipends) to improve retention.

As many of the issues raised in the Listening Project are within the scope of organisational change, there will be opportunities to intervene by mitigating the factors that push staff to leave and by enhancing the factors that foster job satisfaction and commitment to the organisation. Critical to these interventions is not adding more responsibilities on staff who are already stretched. The next section looks at concepts from the literature that link to interventions and key issues from the Listening Project.

5.2.2 Job satisfaction: The ABC model and job crafting

In the Listening Project we heard many subtle examples of staff actively transforming their working conditions to increase job satisfaction and match it to their needs and abilities regardless of the job description. Examples of these were adjusting the roster to avoid staff being transferred to other wards or actively creating a sociable atmosphere with the small team and patients to make work enjoyable.

In the field of working psychology this behaviour to actively redesign their job is referred to as job crafting and goes beyond employees’ values or the characteristics of the job itself. Wrzesniewski and Dutton (2001) who introduced the concept suggested that the motivation to job craft comes from the need for control, social connection and building a positive self-image. It will always take place either formally or informally. Having the opportunity and motivation to job craft determines the form and extent of it (Yang et al., 2021).

Job crafting has been divided in three types (Wrzesniewski et al., 2013).

• Task crafting - the employee alters activities in their role, for example, starting new tasks, stopping existing tasks or changing particular tasks.
• Relational crafting - the employee looks to change the interactions with others
• Cognitive crafting - the employee changes the perception they have of their role

West et al. (2020) looked at needs in more depth and argued that nurses and midwives have three core work needs that must be met to ensure wellbeing and motivation at work and minimise workplace stress. They call these needs the ABC model:

• Autonomy - the need to have control over their work lives, and to be able to act consistently with their values.
• Belonging – the need to be connected to, cared for, and caring of others around them at work, and to feel valued, respected and supported.
• Contribution– the need to experience effectiveness in what they do and deliver valued outcomes.

Interventions can help facilitate people redesign their job from the bottom up (as they do anyway) to help meet these core needs and improve the way people feel towards their role (i.e. cognitive task shifting). Options are, among others, increasing opportunities to listen to staff, flexible working, self-governance models, and giving more agency to staff over being transferred to other wards.

5.2.3 Intergenerational challenges

In the Listening project some participants with many working years’ experience questioned the attitudes of students as some of the latter appeared unprepared to talk with patients or seemed only interested in the more challenging, technical aspects of the role. Also, some students and newly qualified staff commented on the martyr approach of some of the staff, questioning their attitude of working above and beyond their job description and expecting them to do the same.

Research on the dynamics between generations in the workplace shows that awareness of the generational mix of staff in the team or ward can help with understanding broader viewpoints and attitudes. In turn this can prevent the triggering of age-based stereotypes, which can lead to potential conflict and misunderstandings within teams and undermine job satisfaction for different generations (Todd, 2024).

Also, the transition period from being a student to being a registered nurse or midwife is well documented to be a ‘reality shock’. Awareness of potential intergenerational challenges can help with creating supportive environments, which is known to be a protective factor of people leaving (e.g. Ho et al. 2020; Wray et al, 2021).

The literature (Chicca and Shellenbarger, 2018; Tan, 2023; Todd 2024) shows that:

• Generational characteristics over generations show differences in attitudes toward work (e.g., norms, values, rules, and management), orientation toward technology and communication styles, and appreciation for work-life balance and personal growth.
• Research on work values over generations indicates that leisure values and extrinsic values increased, and altruistic work values (such as helping, societal worth) and intrinsic values (such as an interesting, results-oriented job) declined.
• Research on Gen Z indicates that growing up with digital technology and social media can lead to a shorter attention span reduction and in face to face communication skills.

5.2.4 Personal wellbeing and workplace related factors

Participants in the Listening Project gave ample feedback on how they felt (e.g. exhaustion, internalising, feeling the thread of their NMC registration being at risk) when daily work became intolerable due to circumstances outside their control even when raised with managers. While selfcare initiatives could be useful participants were aware that it also gave the impression that the staff needed fixing and the underlying causes of poor wellbeing remained overlooked. Also, there were participants who took offence at selfcare initiatives that were perceived as a tokenistic (e.g. posters on the wall, and empty words).

Flemming (2023) reports that interventions focusing on individual-level factors to improve the resilience and wellbeing without addressing the wider organisational factors are less effective or a cause for resentment. The latter is a widely reported issue in the period since the pandemic from nurses in multiple countries as it implies that the responsibility of looking after staff’s wellbeing lies with the individual staff members rather than the organisation (Buchan and Catton, 2023).

Acknowledging that job burnout is related to workplace-related factors means that the focus shifts from mainly building nursing resilience and putting the onus on them to find solutions for workplace challenges to a broader perspective/collaborative approach of addressing the underlying organisational factors (De Vries et al., 2023; Flemming, 2023).

5.3 Increasing the impact of policy bundles

The Listening Project findings illustrate the growing evidence on the challenges faced by midwifery and nursing staff and students. The different literature perspectives on job retention demonstrate further the complexity and multi-dimensionality of the factors influencing job satisfaction and retention. It also clarifies how future interventions need to be conceptualised, aligned and co-ordinated to create working environments that offer an attractive and rewarding career for midwives and nurses.

This is important because effective policies to improve retention and attraction of the workforce must be underpinned by a clear understanding of the work experiences and motivations of future and existing nurses and midwives. Also, interventions at different levels (e.g. at local or national level) and time frames need to be aligned or co-ordinated (called policy bundles) for maximum impact (Buchan and Catton, 2023).

This complex task is the focus of the Ministerial Nursing and Midwifery Taskforce.