Outgoing Welsh CNO warns of need to protect the workforce

Attention must be paid to the negative impact of Covid-19 on the wellbeing of nurses and how it could also badly affect staff retention, the outgoing chief nursing officer for Wales has warned in an exclusive interview with Nursing Times.

“I am really proud that what we came up with wasn’t some kind of arbitrary piece of legislation, but was practical and empowering to the frontline staff”

Jean White

“I worry about their wellbeing, the stress of the pandemic and their worries about it,” said CNO for Wales Professor Jean White, who is due to retire at Easter.

“We have got some terrible months ahead of us and I am worried about my fellow health professionals and how they are going to cope with this. It is a heavy burden for our nurses and midwives.”

There were also “years of recovery” ahead to get services back to where they were before the pandemic, she noted, including a backlog of patients and greater demands on mental health services.

Staffing would be an ongoing problem for her successor and nurse retention, in particular, would be a “big challenge”, she said.

Professor White said she had wanted to prioritise developing and strengthening the nursing workforce throughout her 10 years in post.

Reflecting on her legacy, she said she was pleased with efforts to boost nurse training capacity in Wales and that it had been the first country in Europe to secure nurse staffing legislation.

However, Professor White, who trained as a general nurse in Swansea and practised as a theatre nurse in Wales and London, told Nursing Times she felt ready to “hand over onto someone else”, noting that “fresh ideas are a good thing”.

She will leave at the end of the current Welsh Government’s term, having served two full terms in the CNO role, which involves being lead professional adviser on nursing and midwifery to ministers and nurse director for NHS Wales.

She is the policy lead for a range of areas including maternity services, breastfeeding, patient experience, safeguarding in NHS Wales, health of people with learning disabilities, and implementation and extension of the safe staffing legislation.

Prior to becoming CNO in October 2010, Professor White held positions in nurse education, at the Welsh National Board, Health Professions Wales and the Welsh Government.

She is also currently a nurse advisor to the World Health Organization’s European region and was awarded a CBE in the 2017 Queen’s Birthday Honours list.

In her time as CNO, Professor White said she had “really focused” her attention on how she could help develop and strengthen the nursing workforce.

She highlighted that for the seventh year running Wales had seen an increase in the number of places for nurse training.

In December, ministers promised an increase in training places for 2021-22, with places for mental health nursing rising from 356 to 410, for adult nursing from 1,400 to 1,540, and for children’s nursing from 159 to 175 – though nothing was confirmed for learning disabilities.

The Welsh Government has also retained the NHS bursary for student nurses and midwives, covering the costs of fees and providing a “small” living allowance, which starts at £1,000. To get the allowance, students must commit to work in Wales afterwards for two years.

Overall, there were now “more nurses working in Wales and have been trained in Wales than at any time in 20 years of devolution”, according to Professor White.

A standout moment for her was the introduction of the Nurse Staffing Levels (Wales) Act 2016, which saw Wales become the first country in Europe to introduce laws on safe staffing levels.

She said she was “delighted” with the way it had “empowered” nurses and given senior nurses the authority to tell their health board the level of staffing needed.

Work was currently underway to extend part of the act, which currently only applies to adult medical and surgical wards, to paediatric inpatients. She anticipated it would be implemented in 2022.

There was also ongoing work to extend the act to cover district nurse-led community teams, inpatient mental health facilities and health visiting – though Professor White said this work had “slowed down a little bit” during the pandemic.

Due to a “global shortage of nursing staff”, the legislation had “not been without its challenges”, she noted.

She added that the law “isn’t a panacea to say, ‘I’m waving a magic wand and every ward has the level of staff we would like to see’”.

“It gives you a methodology to determine what you should have and then it sets out a number of risk-based actions you can take if you haven’t got those staff,” said Professor White.

“I am really proud that what we came up with wasn’t some kind of arbitrary piece of legislation, but was practical and empowering to the frontline staff.”

She continued that it “recognises real challenges” about vacancies, noting there “just aren’t the nurses out there to fill them”.

There had already been challenges with filling nurse vacancies and workforce issues, said Professor White, but since Covid-19, staff pressures had been “exacerbated” further and she was worried about nurse wellbeing.

“We already had workforce challenges that we were trying to manage and then Covid hit,” she said. “Now we are well and truly in a second wave of the infection, and with it brings heavy demands on the workforce.”

There are currently around 22,850 whole-time equivalent nurses employed by the NHS in Wales. But neither the Welsh Government nor NHS Wales currently publish national figures for nursing vacancies.

A report published by the Royal College of Nursing in Wales at the end of last year estimated there were more than 1,600 posts vacant.

Meanwhile, at the end of last year, coronavirus infection rates were climbing in what the country’s government described as an “alarming rate”, leading it to place the nation under its toughest Covid-19 restrictions.

Looking to the future, Professor White said staffing challenges would remain a problem.

While work to support more people to study and work in Wales was helpful, there also needed to be a focus on retention, particularly in the wake of the pandemic, she said.

“We have to pay attention [to] the impact of Covid on the wellbeing of the existing workforce,” she told Nursing Times.

“How many people are going to take early retirement, because they can’t do it anymore?

“I am worried about how many people will leave because the emergency is over, and they are tired and will go.”

She warned that retention could be a “big challenge for the future”.

In terms of wellbeing support for the profession, Professor White highlighted a “whole pack of resources” that were available, including help and advice lines.

“To be a CNO is the most wonderful privilege, and it is somewhat humbling that people trust me to be a senior advisor to government”

Jean White

But she recognised that not all staff were aware of such support and stated that “getting it permeated to every single frontline member of staff is a bit of a challenge for us”.

She hoped her successor would continue work to grow the nursing and midwifery workforce in Wales and the expertise within it, and to “make sure that everybody has the opportunity to reach their full potential”.

Of course, a new CNO would “come in with their own plans and priorities and desires”, she said.

“But for me it has always been about, if you don’t have a supportive workforce you haven’t got a health service,” she added.

“It’s on the backs of the nurses and midwives that you have a health service, quite frankly.

“That has to be everybody’s priority. Without them, you are not going to have safe high-quality care.”

She would also like the next CNO to continue to raise the global profile of Welsh nursing by liaising with bodies such as the International Council of Nurses and the WHO, taking the opportunity to “showcase what is brilliant about nursing and midwifery in Wales and share the good stuff that we have got going on”.

During her tenure, Professor White said she had “tried to champion action to improve the inequalities and outcomes for people with a learning disability”.

Under her lead, the cross-government Improving Lives programme was launched in Wales, which aims to “tackle” inequalities and support people with learning disabilities living in the country. This was also something Professor White hoped her successor would continue to work on.

She was pleased there was a commitment to retain the CNO role, as she felt “government should have a strong nursing and midwifery voice in it to help it shape policy”.

“You get better policies and better decisions made when you actually have a voice that speaks on behalf of the patient… and has a real world understanding about what the workforce is going through,” she added.

Professor White said she was not planning to take on a nursing appointment post-retirement but was looking forward to taking on voluntary roles as the independent council member to Bangor University later this year and as the new high sheriff of Mid Glamorgan in April 2023.

“To be a CNO is the most wonderful privilege, and it is somewhat humbling that people trust me to be a senior advisor to government,” she said.

“I work my very hardest always to be the best version of myself doing this job, because if you do it right you can affect the lives of 3.1 million Welsh people.”

Asked what her message to the profession was, she said to “try to say ‘yes’ to opportunities” and to “have a little bit of faith in yourself and go for it”.

“Why shouldn’t it be you that is the person who is going to be the next nurse director or next ward sister or the next CNO? My only regret is the things I have said no to, on the whole.”