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Cost-of-living crisis impacts the nursing and midwifery professions

Head of Grants and Impact, Sarah McGloin's, editorial piece for the Occupational Medicine Journal.

Read the full PDF version here.

Not a day passes without mention of the cost-of-living crisis and the impact this is having on society across the UK. An estimated 4.6 million households in the UK are behind on their bills and almost a third of children are now living in poverty.

Being in a household with a full-time worker or where all adults work does not guarantee immunity against poverty resulting in ‘in-work poverty’. This is when employed individuals are regularly unable to meet basic needs in a sustained way. Part-time workers can be susceptible to this, and with latest workforce data for the nursing profession showing 30–34% of registered nurses, and 39% of health care support workers (HCSW) work part-time, they are not always protected from the cost-of-living challenges. A simple measure of this is demonstrated through reports of many National Health Service (NHS) Trusts setting up food banks for their nursing and midwifery staff to access.

The cost-of-living crisis disproportionately affects lower-paid individuals, particularly those working in care homes. The Health Foundation found one in five care workers is deemed to be living in poverty, compared to one in eight of all workers. Ten per cent experience food insecurity, whilst 13% of care workers’ children live in material deprivation.

It is not just those on the lower incomes who are affected. Increased pension contributions and other commitments including childcare have resulted in real-term cuts in take-home pay. Currently, 44% of NHS staff are reporting that they cannot afford their NHS Pension contributions. With nurses and midwives contributing 26% of the Full-Time Equivalent (FTE) Health and Social Care workforce, this indicates 12% of them are struggling to meet their pension contributions which raise concerns for the future.

A key metric which demonstrates the cost-of-living is local average house prices. Depending on the area, these can vary between 2.4 and 14 times the average nurse’s salary. This has implications for the nursing workforce in areas with high housing costs can as less experienced nurses and midwives receive accelerated promotion to higher pay bands to fill vacancies left by experienced staff who have moved away from these cost-of-living pressures. This results in a viscous cycle of high vacancy rates and staff turnover.

In England, 42% of NHS Trusts are reporting the increased cost-of-living is affecting individuals’ abilities to meet the cost of basic needs including food at work. Many nurses are skipping meals to pay for items such as school uniforms. This results in a psychological burden associated with the increase cost-of-living. Seventy-eight per cent of Trust leaders have significant concerns for the mental well-being of staff, with 61% reporting a rise in sickness rates due to poor mental health. Poverty is recognized to have a detrimental effect on physical, mental health and financial well-being.

In July 2019, the monthly sickness average for nurses reported by the NHS was 4.4%. This had risen to 6.6% in July 2022. The figures for midwifery are more concerning, rising from 4.5 to 7.4% for the same period. The main presenting factor for sickness was anxiety, depression and other psychiatric conditions. This is of great concern for healthcare leaders across the UK, as they look to address waiting lists and provide good quality care.

A study of over 1000 nurses and HCSW for Florence, the healthcare platform, found 79% reported the rising cost-of-living was having an impact on their mental health. As a result, 51% of nurses and HCSW reported having to take leave from work, to recover from stress and burnout, whilst 40% reported serious mental health issues associated with these pressures.

The cost-of-living crisis is set within a wider context of challenges to nurses’, midwives’ and HCSWs’ mental health and well-being. Even before the COVID-19 pandemic, there were already considerable demands on these professions. Working long shifts, coupled with staff shortages and what is often distressing work, led to nurses experiencing primary and secondary traumatic stress, burnout, compassion fatigue and moral distress.

The COVID-19 pandemic has also had a significant impact on nurses’ and midwives’ mental health. The Impact of COVID in Nurses (ICON) longitudinal study has identified four themes relating to nurses psychological needs. The four themes are: deathscapes’ and impoverished care, systemic challenges and self-preservation, emotional exhaustion, and (un)helpful support. The issues nurses reported within these themes were moral distress, compassion fatigue, burnout and post-traumatic stress disorder. Many of those interviewed were considering leaving the profession.

The implications of poor mental health due to the cost-of-living crisis for nurses, midwives and HCSW are significant. It is a driving staff to seek positions outside of the healthcare sector, where competitive salaries and less stressful roles. Some 27 130 nurses, midwives and nursing associates left the Nursing and Midwifery Council (NMC) register in 2022, with 33% citing stress and excessive pressure, had led to their poor mental health. Such increases in staff turnover are not only costly for organizations, but also impact on their ability to provide an efficient and effective healthcare system.

To try to address the stress and mental health challenges nurses, midwives and HCSW are experiencing, NHS organizations are working in partnership to provide additional community support for both their employees and patients. This includes moving to digital remote services, providing referrals to food banks, debt advice, financial education and financial support. Twenty-seven per cent of NHS Providers now have in-house food banks for staff and 14% of nurses and HCSW have reported using these. Whilst these are pragmatic responses to support the workforce in an unprecedented situation, many organizations are concerned as to how sustainable these interventions will be in the longer term.

The reality of the impact of the cost-of-living crisis on nurses, midwives and HCSW is also reflected in the experiences of charities which work to support the nursing and midwifery professions.

The increases in cost-of-living for nursing and midwifery staff are reflected in the experience of the RCN Foundation’s Benevolent Service. This independent nursing and midwifery charity provides eligible nurses, midwives and HCSW with hardship grants and provides a signposting service to all nurses, midwives and HCSW across the UK, who are facing financial hardship.

In 2022, the Foundation has provided 618 hardship grants to nurses, midwives and HCSW in comparison to 377 over the same period in 2021. This represents a 64% increase in applications. Eighty per cent of applicants were employed, with 64% in substantive posts, and 16% employed as agency or bank nurses. For many, their total net income was insufficient to meet their basic needs, indicating in-work poverty. Whilst 56% of grant recipients report debt as their main issue, this is accompanied by other issues including poor mental health (56%), and physical health (30%).

The impact for individuals of being in debt is that it prohibits access to basic services including broadband. A lack of access to such utilities has resulted in ‘data poverty’, when individuals are unable to afford sufficient, private and secure data either through broadband or mobile devices, to meet their essential needs. The ‘What is data poverty’ rapid review found this resulted in fewer opportunities for people to engage with the online world, which in turn causes a digital divide, with individuals becoming ‘data poor’. Being unable to access online resources was recognized to impede life chances and increase social isolation. In particular, being unable to go online due to data poverty has a negative impact on well-being and limits economic opportunities, with individuals often being unable to access job searching sites and to apply for suitable positions. Consequently, with access to the internet being fundamental to accessing many services and opportunities, a lack of access exacerbates inequality and hardship.

Another worrying trend is a sharp increase in the number of nurses, midwives and HCSW who are experiencing hardship as a result of fleeing domestic violence. Sixty-seven (14%) of the grants awarded by the RCN Foundation in 2022 have gone to survivors of domestic abuse. This reflects a national trend with Refuge seeing an increase of 61% in calls to its helpline between 2020 and 2021. Frequently this need relates to furniture and flooring for a vacant social housing property that has been allocated in a safe location, often away from where they normally live.

The number of applicants mentioning challenges with petrol costs for work journeys rose by a staggering 87%, in April 2022, compared with January 2022. This is particularly important for nurses and midwives providing services in rural locations who are struggling to pay for fuel.

This whole picture is resulting in calls for a nationally co-ordinated approach to providing sustained support to staff and patients with the increased cost-of-living. The ambition is to ensure nurses, midwives and HCSW can continue to provide patient-centred care, without damage to their own mental health and emotional well-being due to the pressures caused by financial hardship.