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The NHS staffing crisis is severe in mental health, with many early-to-mid-career nurses leaving, but there are ways to make staff feel valued and want to stay
In the context of the ongoing staffing crisis, ensuring qualified nurses stay in the profession is vital. So the fact that an increasing number of mental health nurses are choosing to walk away within a few years of qualifying is a cause for concern.
Mental Health Practice. 26, 5, 11-13. doi: 10.7748/mhp.26.5.11.s6
Published: 05 September 2023
‘Historically, the highest concentration of leavers came from the older age range of mental health nurses – 55 and over – which would include those leaving due to retirement,’ says NHS England’s deputy chief nurse Liz Fenton. ‘However, recent data has highlighted that the greater numbers of leavers now include those who have been in the workforce for 25 years or more, as well as those in the first five years of their career.’
Workforce shortages are a major challenge for the NHS as a whole, with more than 40,000 nurse vacancies in England alone. But the situation is even more stark in mental health nursing.
A report by the Nuffield Trust for the NHS Confederation published in May, shows that while there has been an 11% increase in the number of mental health nurses since 2015, this is half of the growth in children’s and adult nursing.
The latest NHS vacancy statistics show 18% of nursing posts at mental health trusts were unfilled as of March 2023 – unchanged since the previous quarter. And almost one third (30%) of all nursing vacancies are in mental health trusts.
Mental health nurses leaving the profession when they are in early or mid-career is a major issue for employers, service users and other nurses, according to Nuffield Trust senior fellow Billy Palmer.
‘Mental health trusts have very high vacancy rates,’ says Dr Palmer, who is also lead author of the trust’s recent report on mental health nursing. ‘Having unfilled posts can come at an additional cost and burden for providers and affect the ability to provide care.’
Dr Palmer says one of the problems of poor staff retention in mental health nursing is the risk of a vicious cycle. ‘When staff leave, staffing levels and workforce pressures worsen and are key reasons for others leaving.’
Mental health nurses leaving the profession early also means there is a risk of ‘losing nurse leaders and role models’, says RCN professional lead for mental health Stephen Jones. ‘We’re also losing people’s competence, skills and knowledge, which are needed to develop the workforce.
‘And without the experience of mid-career mental health nurses, and the ambition and willingness to change of the recently qualified, there will be challenges for those coming into the profession.’
While pay and the impact of the pandemic on well-being are among the issues why so many mental health nurses are leaving the profession, there are also other important reasons, says Mr Jones.
Janet Idowu (pictured), service manager of a personality disorder ward at a private mental health hospital in London, has left the NHS but stayed in mental health nursing.
‘My first degree was in law, but I quickly realised law wasn’t for me. After working for the NHS 111 service, which included supporting patients with mental health issues, I decided mental health nursing was for me,’ she says.
‘Since qualifying in 2017, I’ve had several mental health nursing jobs at an NHS hospital in London. I didn’t get much support in my first job on an acute ward. I enjoyed my second role as a discharge coordinator, but with so many staff leaving I ended up doing three people’s jobs. I had to leave or I would have become completely burnt out.
‘Eventually, I became a clinical service lead for three acute wards. While I was in my element supporting nurses and patients, I felt exhausted every day, dealing with the pressures of staffing shortages.
Exhaustion drove me out of the NHS
‘I started out with so much enthusiasm but got nothing back. I’d suggest changes to improve services, but there were too many hurdles to jump over to make even small changes happen.
‘I was at the end of my tether – I was exhausted after the pandemic but I had to do overtime to make ends meet. Despite this, I still felt mental health nursing was the career for me.
‘Last October, I left the NHS to work at a private mental health hospital in London. I’ve loved every minute of my work since, and unlike my previous job it doesn’t drain me mentally or emotionally. I can be my true self here – I’m full of ideas and my enthusiasm is appreciated.
‘I still love the NHS and can see myself going back to it. I’d like to be someone driving change within it but I couldn’t go back to the service as it stands.
‘There needs to be better support, working conditions and pay for mental health nurses and more investment in the specialty. There needs to be more mental health nurses, more mentors and more opportunities for career development.
‘And we need to make sure people working in the NHS don’t burn out. My generation of nurses are not going to sacrifice life for work anymore –our mental health comes first.’
‘Mental health nursing is about supporting and connecting with people,’ he says. ‘Mental health nurses go into the profession wanting to have a positive impact on people’s lives. Often they will have an expectation of what they can bring to a service or to patient care.
‘But they may be met with different challenges that do not allow them to practise the best way they feel they can. The system, the environment, the culture may constrain them from doing that.’
Mental health nurses may be dealing with ‘massive case loads’, be lacking support and working in an environment where ‘paperwork is prioritised over care giving’, Mr Jones adds.
In this context, the willingness to stay in the job when better pay is available elsewhere may erode. Unite’s lead professional officer for mental health Dave Munday says: ‘If they have the opportunity for a better life for themselves and their families by working in a different environment, they will take those options.’
For some this may mean switching to private providers or nursing overseas, but many will pursue completely different careers offering better pay and conditions, such as in the hospitality industry, says Mr Munday.
Mr Jones points to a lack of clinical career opportunities in mental health nursing and says that ‘far more needs to be done to value the profession’.
‘Mental health nurses need to be heard,’ says Mr Jones. ‘There need to be better direct communication channels between those who provide care and those creating strategic priorities.
‘Employers and managers need to ensure there is a true open-door policy and that mental health nurses have a voice and feel part of the decision-making process.’
Similar issues were raised in Health Education England’s (HEE) 2022 review of the mental health nursing workforce. One response to this is the ongoing development of a ‘career pathway document’ for mental health nurses, which NHS England and Ms Fenton are working on.
‘It is being developed to celebrate and raise the profile of the diversity of roles within mental health nursing,’ says Ms Fenton.
‘It will provide a clear pathway to support mental health nurses to grow and develop their skills and provide an outline of the skills they need to develop in order to progress.’
The NHS Long Term Workforce Plan, published in June, singles out the shortfall in mental health nursing as being ‘of particular concern’ and lays out the aim of increasing the training places for mental health nursing by 38% by 2028-29.
There are also proposals to allow nurses to move into employment earlier on completion of their degree. ‘If managed well, this could provide an effective transition into the NHS for newly trained nurses but could be counterproductive if managed poorly,’ says Dr Palmer.
‘If you take care of your staff, you’ll be taking care of your patients. The health and well-being of staff is not just a nicety – it’s a statutory responsibility and it can’t be forgotten’
Stephen Jones, RCN professional lead for mental health
But there are big, long-term issues that may be hard to tackle. Pay is a major issue for nurses and ‘significant pay cuts in real terms over the past two years should be addressed’, says Mr Munday.
Mr Jones highlights a need for specific continuing professional development, flexibility in career paths and roles, an improvement in workplace culture, and better support around nurses’ own mental health to ensure more mental health nurses stay in the profession.
More immediately, having ‘visible leadership’ to offer support to mental health nurses on the ground, is a ‘powerful change’ that could be easily introduced straight away by employers and managers says Mr Jones.
‘Mental health nurses working in understaffed environments with challenging cases need strong nursing leadership so they feel supported. Having a head of nursing, for example, who goes to staff on the wards to let them know that the support is there, and asking if they are okay, showing real, compassionate leadership,’ he says.
With the redesign of how services are commissioned in the NHS and the introduction of new integrated care boards it is important for more mental health nurses to be in leadership roles and to have a voice on these boards ‘to help shape mental health services and how they look in the coming years’, says Mr Jones.
Ultimately, improving retention in mental health nursing is about taking care of nurses. ‘If you take care of your staff, you’ll be taking care of your patients,’ says Mr Jones. ‘That care is not always a priority, but the health and well-being of staff is not just a nicety – it’s a statutory responsibility and it cannot be forgotten.’
