Nurses open up about their mental health problems

Mental ill health is now the top reason for NHS sickness absence – but there is good news

• Musculoskeletal conditions have been replaced by mental health problems as the most common reason for sickness absence among NHS staff, including nurses and midwives
• Employers and managers are seeing a shift in levels of support offered and demanded, with staff no longer expected to 'just get on with it'
• Mental health first aid training allows staff and employees to reconsider their approach to offering colleagues support

It was a heartfelt blog from a senior nurse that sparked a trust-wide conversation about mental health at Leeds Community Healthcare. Writing on the trust’s internal website, the nurse spoke about her struggles with mental health – and the response was electrifying.

‘She was really open about her own experience, and she was inundated with people coming forward and saying how much she had reflected their own issues and perspectives,’ says the trust’s director of workforce, Jenny Allen.

‘People were saying it was great that she had been so honest, and had been able to open up the conversation.

‘I think the reason why she felt able to be open, and others felt able to respond, was largely because of the culture that we’ve created in the organisation. We’ve tried to have an open and honest and supportive culture, one in which people – staff – are placed first.’

An open conversation about mental health

As a direct result of this blog, the trust set up an event called an open conversation, where people could share their own experiences. The first event was packed out, and it has become a regular feature.

‘There were quite a lot of clinicians there, the chief executive, and some of the directors,’ says assistant director of workforce Ann Hobson. ‘Some individuals were sharing for the first time that they’d had a mental health problem; in some cases their family didn’t even know. People felt they were able to talk and be open, which was great.’

The mental health of NHS staff has come under the spotlight since it emerged that mental health conditions have overtaken musculoskeletal problems as the number one cause of sickness absence.

• RELATED: Too stressed to work: the scale of mental ill health among NHS staff revealed

The official figures from NHS Digital show that NHS staff in England took 17.7 million days of sickness leave between December 2017 and November 2018 – 4.2 million (23.7%) of which were attributed to stress, anxiety, depression or other mental health conditions. This compares to 980,157 days lost to back problems in the same period, 1.86 million to other musculoskeletal problems, and almost 1.5 million to colds and flu.

‘Frequently cited causes of poor mental health at work include things like long and unsociable working hours, a reactive environment and excessive caseloads, all of which are commonplace within nursing’

Emma Mamo, head of workplace well-being with the mental health charity Mind

More recent, provisional monthly figures, which give a breakdown of sickness absence rates by professional group, suggest that this high rate of mental health-related absence across the NHS workforce is most likely reflected in the rates for nurses and midwives alone. The figures show that in April 2019, anxiety, stress, depression and other psychiatric conditions accounted for 24.7% of sickness absence among all staff, around the same proportion as for nurses and health visitors (24.4%) and slightly less than for midwives (26.6%).

It all adds up to the NHS losing a staggering amount of staff time, putting pressure on those staff who are coming into work, not to mention the burden on those who are off sick.

• RELATED: The toll emotional labour takes on our mental health

Difficult work environments, unsocial hours and caseloads can take their toll

The figures come as no surprise to Emma Mamo, head of workplace well-being with the mental health charity Mind. ‘Considering how much time we spend at work, it’s not surprising our working environment can have a dramatic impact on our mental health and our well-being,’ she says.

‘Nurses play a vital part in supporting us when we are unwell, but they do a hugely challenging job, often in extremely difficult circumstances.

‘Frequently cited causes of poor mental health at work include things like long and unsociable working hours, a reactive environment and excessive caseloads, all of which are commonplace within nursing.

‘We know increasingly workplaces are taking this seriously and supporting staff in the right way, but there is still a long way to go.’

Mind and money: how does work affect your mental health? 

The Cavell Nurses’ Trust, which helps nurses, midwives and healthcare assistants suffering personal or financial hardship, is currently running a Mind & Money survey looking at mental health issues among nursing professionals.

‘Mental health issues affect everyone, and we wanted to better understand these issues affecting the people we help every day,’ says chief executive John Orchard.

‘We record the primary reason for people contacting the Cavell Nurses’ Trust for help. From October 2016 to July 2018, 49% of the people we helped were recorded as having a health problem. Of these, 25% said their problem was to do with mental health or behavioural issues.’

The organisation hopes the survey will provide more information about nurses’ working environments and the impact this has on mental health. A previous survey (in 2018) showed that feeling valued, and having open and engaging relationships between employers and employees is part of having good mental health provision at work.

The Cavell Nurses’ Trust Mind & Money survey is open until 1 November.

Higher number of sick days indicates reduced stigma

Mental health campaigner and coach Lisa Rodrigues believes there is a positive side to the high number of sick days attributed to mental ill health: it means that people are acknowledging the real reason they are taking time off. ‘Stigma certainly hasn’t gone but it is reducing, and people are prepared to say “look, I’m off with stress” rather than pretend it’s a back injury or something else.’

Ms Rodrigues started working in the NHS in 1973 as a nurse and then a health visitor, before going into health service management, including spending 13 years as chief executive of Sussex Partnership NHS Foundation Trust. She has also had many years’ experience of mental ill health – which is something she tried to hide for much of her working life.

• RELATED: Lisa Rodrigues: What it's like to lead a mental health trust while dealing with depression and anxiety

‘Near the end of my career I had an acute episode of depression. I’m really pleased that I was able to tell people why I was away from work. I went back on a return-to-work programme and got really good support from members of my team and my chair and managed to do the last seven months, which were probably the best seven months of my career. My biggest regret is that I didn’t tell people about it to start with. I think I would have been a much better chief executive if I had.’

Hiding my own mental health struggles while trying to help staff

The paradox, she says, is that while she was, in effect, hiding her own struggles, she was implementing policies to improve the mental health of her workforce. She would like to see a step change in the health service as a whole. ‘The NHS is still very focused on targets and outcomes and getting things done and that is sometimes to the detriment of how it feels to be a member of staff, who is a human being, and who is really struggling to achieve those things,’ she adds.

‘Very often people go home after a long shift feeling a sense of utter, utter failure because they haven’t managed to do everything they were supposed to do… everything feels impossible for them, and there’s nobody to talk to; they don’t get a debrief at the end.’

Ms Rodrigues, whose blog Lisa Says This, and book, Being an NHS Chief Executive: What they never told me or if they did I wasn’t listening, tells more of her own story, would like to see less focus on critical incident reviews that look for ‘one cause’ if something goes wrong, and more on supporting staff as human beings.

• RELATED: Stand up to the stigma of mental illness

How can leaders ensure team members are supported?

NHS Employers chief executive Danny Mortimer says the levels of sickness absence due to mental ill health and stress among nurses are a concern for leaders. ‘It remains a vital undertaking for our leaders to ensure that all members of our teams are properly cared for, whether they are in crisis or to prevent them reaching that point,’ he says.

‘At a time when we are faced with major shortages of nursing staff, it is vital that we make sure nurses have the support they need to recover and return to work.’

He points to a number of national initiatives, including the report Thriving at Work: a review of mental health and employers, by Paul Farmer and Lord Dennis Stevenson, which sets out mental health core standards for employers, and the NHS Health and Wellbeing Framework, which helps organisations plan and implement their own approach to improving staff health and well-being. 

• RELATED: Resilience: the knack of bouncing back from the bad days

Health and safety also applies to psychological hazards at work

Chris O’Sullivan, head of workplace mental health at the Mental Health Foundation, says that it’s not surprising that healthcare staff are feeling under strain, not just because of the pressures in the system but because of wider factors like austerity. He would like to see a greater focus on prevention. ‘The level of psychological hazard that nurses face is high,’ he says.

• RELATED: NHS People Plan is refreshingly honest about the causes and extent of nurse burnout

‘Everyone in every workplace, be it nursing or construction, understands the Health and Safety at Work Act, and understands the need for personal protective equipment. But it’s rarely understood that the act applies equally to psychological hazards, and the same duties apply to protect and mitigate against them as they do to physical hazards.

‘So while you would never say to a nurse to do that job without gloves because it will be quicker, you might ask a nurse if they can stay an extra three or four hours because your patients need you, knowing that they, being nurses, will almost certainly do that.’

• RELATED: Nurses struggle to access clinical supervision and employer initiatives to improve well-being

Some employers do recognise and act on this. Leeds Community Healthcare’s wider approach to supporting the mental health and well-being of staff is showing good results. The open conversation project is part of a suite of initiatives that include having staff trained in mental health first aid, regular supervision for nursing staff, training in stress management, and an eight-week mindfulness course.

Perhaps not coincidentally, the trust is experiencing a fall in overall sickness absence, dropping from a relatively high 5.8% in 2017-18 to 4.8% in the past 12-14 months.

Staff expectations regarding mental health support are changing 

Practice development nurse Anna Bray, of London’s Whipps Cross Hospital, part of Barts Health NHS Trust, believes attitudes are changing for the better. She works in the children’s ward, supporting 60 members of staff with their education and development needs, and has a bigger trust-wide role supporting paediatric teams. The mental health of nursing staff is a priority, she says.

‘More and more we’re seeing a shift in expectations from staff. When I started nursing about 15 years ago you kind of “got on with it” and that was what was expected of you. If you moaned about it then you “just weren’t keeping up”. Now that’s very different.

‘People expect to be supported, which is right, and they probably don’t put up with as much as I remember putting up with 15 years ago. They want you to support them with clinical needs, but also they like – as we all do – being recognised for good work and good practice, and they want things to be fun and engaging.’

• RELATED: Implementing laughter therapy to enhance the well-being of patients and nurses

She points to the ward’s twice-yearly medicines management week, which combines learning and information with a token of appreciation. In August, nursing staff who took part in the learning sessions were given a ‘survival kit’. ‘On one side it had the eight Rs [a system to improve safety of medicines administration by making sure you have the right patient, right medication, right dose etc], but on the other it had a silver star – because they are a star,’ she says. ‘It also has a tea-bag, for when they need a cup of tea, a chocolate for when they need a pick-me-up, and a hair band.’

It’s a small gesture that sends out an important message: ‘We’re saying that we value staff and we understand the pressure they are under.’ 

Jennifer Trueland is a health journalist