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Workforce needs its own care plan

The emotional labour of nursing takes a toll; a concerted effort to limit its effects is essential to the future of healthcare.
By Scott Lamont, Scott Brunero and Lin Perry

Internationally, healthcare organisations face the challenge of retaining a healthy yet ageing nursing workforce.

Nurses make up the largest single professional group in healthcare and have the oldest average age – which is increasing. Their work is recognised as emotionally, psychologically and physically demanding, with cumulative effects. Research evidence indicates they can experience high levels of sickness and work absences, stress, anxiety and depression (referred to as common mental disorders – CMDs) and low vitality.

Research shows that precursors for CMDs and low vitality relevant to the nursing workforce include workplace violence, shift work, work environments where nurses lack autonomy but experience high demand and low support, inter-professional conflict and exposure to trauma, and substance use as a coping mechanism.

Given these risks, the health of nurses should be a high priority within healthcare workforce planning. The implications of nurses experiencing sub-optimal health go beyond the wellbeing of these individuals; reduced productivity, medical errors, safety issues and inability to engage in core and compassionate care have all been highlighted.

Recent high-profile examples showed workplaces devoid of care for staff, with similarly uncompassionate care delivered to patients. The very essence of nursing is challenged by the presence of CMDs and low vitality.

Yet, despite all these risks, the health of nurses does not receive attention commensurate with need.

This led us to investigate the mental health of RNs and enrolled nurses at two teaching hospitals in Sydney in 2011–12. Using a cross-sectional survey design, we invited participation of all RNs and enrolled nurses at the study sites. The survey also explored aspects of physical health and wellbeing reported elsewhere.

A total of 1215 surveys were distributed, with 382 usable responses (31.4 per cent). The results showed 14 per cent of nurses reported a history of mental health disorders; of those, 13 per cent listed diagnoses of anxiety and/or depression and 6 per cent were taking psychoactive medication. Responses to some questions suggested greater numbers affected than the 14 per cent reported; for example, 65.1 per cent indicated they had experienced symptoms potentially consistent with mental health disorders sometimes or often in the preceding 12 months.

Our results indicated that better general health, living with a spouse or partner, having fewer sleep problems and disordered eating habits, not being an informal carer and not working nights were all predictive of better mental health. The study highlighted key issues for addressing health in general – but also mental health-related issues – in the nursing workforce. This work has been taken NSW-wide, with more than 5000 nurses responding; analyses are now in progress.

Awareness comes first

Early identification of CMDs and other mental health issues is essential to providing safe workplaces and a supported nursing workforce. Programs such as mental health literacy, which encourage awareness activities, need embedding into nursing workforce planning and cultures.

The term mental health literacy describes knowledge and beliefs about mental disorders that aid their recognition, management and prevention. Poor mental health literacy amongst health professionals may compromise the recognition and management of CMDs in nursing peers.

Mental health-related stigma continues to be a barrier to self-report and peer support. Developing increased levels of mental health literacy across the spectrum of the nursing workforce may be a crucial first step in developing screening and support programs.

National Mental Health Week, which occurs in October annually, is an opportunity for services to hold events to raise mental health awareness and literacy. This year, the authors have various activities planned that are intended to raise awareness, address stigma and place this topic on organisational agendas.

Healthcare organisations can also establish wellness programs based on evidence-based interventions. New technologies such as smartphones and apps can be used to provide nurses with accessible information, support and activities, many of which employ a wide range of techniques to focus on mental health vitality and wellbeing.

Confidential support

Historically, healthcare organisations have provided supportive services to nurses who either self-report, or are perhaps reported, to registration bodies. Today, however, employee assistance programs, once part of workforce services, are increasingly being outsourced to private organisations with consequent loss of some degree of proximity and intimacy. However, stigma and lack of awareness have been discussed as deterrents that were in place even before the addition of the geographical barriers.


Our study highlights the importance of proactive and visible yet confidential screening, support and referral programs within healthcare provider organisations, such as can be offered through the occupational health departments, which were once popular within hospital networks. Such departments continue within healthcare organisations in the UK, with an estimated 7000 occupational health nurses within healthcare.


Development of such programs requires strong links to GP services, community crisis teams, psychiatry and psychological services within local communities, preferably supported by wellness programs grounded in evidence-based literature. These would provide the support to enable individual nurses to maintain wellness, as the challenges of doing this unsupported are considerable.


The problem with presenteeism

Without such support, the greater the chance that affected nurses either have extended sickness absences or continue to attend work whilst their capacity to function is impaired.


Whilst much is known and documented about the prevalence and effects of healthcare absenteeism, there is little in the way of organisational engagement that seeks to explore the extent and effects of healthcare presenteeism.


Presenteeism – attending work whilst sick – is arguably a greater healthcare problem in relation to inefficiency and reduced productivity, patient and staff safety and wellbeing. The financial burden for healthcare organisations is difficult to quantify but likely to be substantial. It has been suggested that it accounts for 1.5–4 times more working time lost than absenteeism, with Australian estimates proposing about a $35 billion cost for employers in 2009–10. As a first step towards addressing this issue, instruments such as the Stanford Presenteeism Scale can be adopted to incorporate CMDs for estimates of their effect within the nursing workforce.


Compassionate workplaces

Healthcare organisations need to create supportive workplaces for nurses to maintain health and wellbeing. Workplace cultures that have accessible relevant infrastructure and are free from mental health stigma are essential in supporting the health and wellbeing of nurses. Awareness and wellness programs, and screening and referral processes, designed to create compassionate workplaces supporting staff in delivery of compassionate care, are the first steps to addressing this neglected issue.

Scott Lamont and Scott Brunero are RNs and clinical nurse consultants, mental health liaisons, at Prince of Wales Hospital Sydney. Lin Perry is professor of nursing research and practice development, also at Prince of Wales Hospital Sydney.

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One comment

  1. Excellent article…so much about the day-to-day reality of Nursing seems to be in direct conflict with good mental & holistic health for the Nurse.
    Somewhere down the line in my nursing career this dawned on me.
    Quite a challenge to address the issues.
    Compounded, I guess with hospital shift-work area of nursing.
    …which most of the time seems far removed from health promotion – sadly.

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