Is nursing a workforce in crisis?

Published 08/02/2023   |   Reading Time minutes

With mounting pressures on NHS services and staff wellbeing at an all-time low, recent weeks have seen nurses taking unprecedented strike action as part of an ongoing dispute about fair pay and patient safety. 

On 26 January 2023, the Chief Nursing Officer (CNO) for Wales appeared before the Senedd’s Health and Social Care Committee to discuss the challenges facing the profession. She told the Committee:

we have incredible staff who are doing an exceptional job under very challenging, very difficult circumstances. … I would certainly say it is perhaps the most challenged position I have seen in my 31 years as a nurse.

The nursing workforce in Wales: key data

Nursing, midwifery and health visiting staff are the largest NHS workforce group, making up 40% of the NHS Wales workforce. At end June 2022, 36,020 full time equivalent (FTE) nursing, midwifery and health visiting staff were employed by NHS Wales, of which 22,790 were registered nurses.

In its Nursing in numbers 2022 report, the Royal College of Nursing (RCN) Wales states that while the broader nursing workforce has increased by 16% since 2012, the number of registered nurses has only increased by 11% - “This growth does not reflect the increase in patient need”.

Nursing is still a predominantly female profession. According to the Nursing and Midwifery Council (NMC) register, 90% of people on the permanent register in Wales are female (this includes nurses and midwives).

Significant numbers of nurses are approaching retirement age. The NMC register shows that 24% of registrants are over the age of 55 (38% are over 50). 

Joiners and leavers

The NMC maintains a register of all nurses and midwives eligible to practise in the UK. Data for Wales shows that in 2021/22, 1,600 nurses joined the nursing register for the first time. 1,401 left. While this may look like an overall gain for the profession, it’s not clear how this translates into numbers within the NHS Wales workforce.

The NMC data represents registered nurses with an address in Wales; it doesn’t show how many are actually working in Wales, or within the NHS. Nor does it necessarily equate to full-time equivalent nurses in the workforce.

The data doesn’t give us further details about nurses leaving the register, including which parts of the NHS have lost nurses.

Vacancies and use of agency nursing

The lack of transparent information on nursing vacancies is a longstanding issue. On 26 January, the CNO confirmed that Wales is still the only UK country that doesn’t publish data on nurse vacancies (this was a particular point of concern for the Committee).

RCN Wales estimates that there are currently at least 2,900 registered nurse vacancies in NHS Wales. It recently reported that in 2021/2022, NHS Wales spent £140 million on agency nursing – “This would pay the salaries of 5,167 full-time nurses”.

RCN Wales highlights that from the perspective of the individual, agency nursing can be very attractive, with better pay and more flexibility over working hours and location.

The CNO said that health boards need to understand what their workforce is asking for, and what will enable agency workers to come back to the NHS. She said it’s not just a question of pay, but working conditions must also be considered.

It is important that nurses get their breaks, it is important that they have a place to take their break, and health boards are working on a number of things to ensure that nurses’ health and well-being are being focused on.

International recruitment

The number of people on the NMC register who trained in the EU/EEA has fallen by 4.2% from the previous year. The number who trained outside the EU/EEA has risen by 14.3% (the majority of these trained in the Philippines and India).

The CNO told the Committee that while increasing recruitment from overseas might be an effective, short-term solution, Wales has to become more self-reliant and recruit more domestic trainees. She also highlighted the ethical impact of recruiting from developing nations, and the possibility of developing some more reciprocal approaches to support the training of international students. 

What next for Nurse Staffing Levels (Wales) Act 2016?

Wales’ nurse staffing levels legislation initially required health boards to calculate and maintain appropriate nurse staffing levels in adult acute hospital wards. Throughout the development and passage of the legislation, there was a clear intention for this requirement (commonly referred to as section 25B) to be extended to other healthcare settings in the future.

From October 2020, it has also applied to paediatric wards.

A recent RCN Wales petition called for section 25B to be extended to all settings where nursing care is provided, starting with community nursing and mental health inpatient wards.

Asked by Committee Members about her ambitions for extending the Act further, the CNO highlighted that we’re now operating in a “very different landscape”.

the Act, when developed nine years ago or so, I think was developed for a time and place and point in time, perhaps. (…) I think we need to think bigger and broader around how we actually use the Act to staff our wards in a way that is smart, that is different, that is multi-professional in nature, because the Act is quite uniprofessional, as you can appreciate, and that is not how patients use our services nor how their care is delivered.

A focus on retention

Concerns about nurse recruitment and retention aren’t new. The nursing shortage is a global issue. Other countries are also seeing high numbers of vacancies, and a growing reliance on international recruitment to fill posts. More sustainable solutions must be found.

While we need to ensure we’re training sufficient numbers of new nurses, improving nurse retention – keeping experienced nurses in the workforce - is arguably one of the most important challenges to address. Listening to nurses will be a key part of this. The CNO told the Health and Social Care Committee:

As the head of the profession, I absolutely acknowledge and understand where nurses and midwives are coming from currently, and it is really disappointing to see that they have been pushed to this point. I do think that they need to use their voices and as I put my head-of-profession hat on, it is important for me to encourage nurses to use their voices for what they require.

Article by Philippa Watkins, Senedd Research, Welsh Parliament