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The Nursing in Practice opinion survey

This survey is an update on the questions we asked you in 2008 on some of the leading issues in primary care nursing today. The results reveal your feelings about working in the current climate and provide an insight into how life has changed for you, personally and professionally, over the past year ...

It would be understandable if, as 2009 begins, nurses do not wish to dwell too thoroughly on the events of 2008 – a year that may be remembered for coining the all-too ubiquitous term
"credit crunch".

Yet, it's worth taking a moment to consider the developments of the last year – not only the dire financial circumstances that have occurred, but also the changes that have taken place in primary care. The first Nursing in Practice online survey was conducted at the end of 2007, a time when the average practice nurse could have been forgiven for believing the word "Darzi" was a poorly pronounced reference to a character from Pride and Prejudice.

Yet "Darzi centres" or "polyclinics" – or "GP-led health centres", as they are more correctly known – were the big talking point of 2008 in primary care, dividing opinion to such extent that a British Medical Association (BMA) campaign was mobilised against them. Nonetheless, several such integrated health centres have already been created, and more will be introduced this year.

In September, it was even suggested that nurses would outnumber GPs by three to one in a "national network of polyclinics".1 So, what do primary care nurses think? Our survey suggests a mixed view: 30% believed the health centres represent a "good opportunity for general practice" that would increase access for patients; yet a slightly larger proportion (32%) see them as a "serious threat to traditional general practice" that could even lead to the closure of existing practices.

Extended surgery opening hours were also introduced last year. Our survey suggests the timing of the new opening requirement could have been better. With the economy in trouble, and at a time of stalled GP pay rises and increased practice overheads, surgeries were unlikely to be in a position to afford extra staff to cover later and Saturday shifts. Perhaps no wonder then that 30% of nurses polled said that, since last year, they were now working longer hours for the same or less pay.

In addition, with only slightly fewer than half (48.7%) of respondents working full time, the current economic climate has placed pressure on part-time nurses whose partners have been made redundant or are facing reduced income at this time. Several respondents reported that their husbands were now out of work. Nearly half (47%) of part-time nurses working less than 20 hours a week said the credit crunch had forced them to work longer hours (see Figure 1).

As well as gauging opinion on these developments, the aim of this survey was to compare the results with those of last year. Somewhat surprisingly, despite the gloomy zeitgeist, nurses generally appeared to be more positive and the clear majority are committed to nursing and to primary care.

Credit crunch
More than half (57%) of respondents said they had been affected by the current economic crisis. "Personally, I have higher outgoings. Professionally, the practice cannot afford to employ another nurse," a practice nurse from Essex commented. A practice nurse in Leeds said, "Everything has increased in price yet my salary only increased by 2% last year – very demoralising."

Indeed, the survey suggests many of you are noticing changes in your professional and personal lives that are having an impact on your ability to cope financially. Other comments included:

  •    "I now have higher household bills and general living expenses" – practice nurse, Staffordshire
  •    "We have a young family and previously coped with financial pressures. Now we have added financial pressures and are not sure how far our 'coping' will stretch" – nurse practitioner, Hertfordshire
  •   "Everyone is more aware of wastage, etc and patients are lower in mood" – practice nurse, Manchester
  •    "I'm unable to pay my mortgage as I only work part-time. We struggle every month. My patients are in a similar position, with no pay increases or any overtime paid" – nurse practitioner, Middlesex.

As a result of the credit crunch, 36% of respondents say they are working more hours, a quarter say they have been forced to take an another job, and more than one in five (21%) have been forced to seek help to manage their personal finances (see Figure 1).

[[Figs 1-3_survey]]

With regards to your current wages, there was a clear split in opinion: 56% thought their pay was "fair", yet 42% believed it to be "unfair"; only 2% stated that it was "generous" – surprisingly, these percentages are exactly the same since as in last year's survey.

Opinion on recent policy
When asked how you feel about the introduction of private sector providers, there have been no changes in the responses received from last year. A total of 60% felt that the introduction of private sector providers poses a major threat to the quality of general practice and to patient care, compared to 61% in the
last survey.
Many more people answered the question about the Quality and Outcomes framework (QOF) this time, with the majority stating that the introduction of the QOF has resulted in moderate improvements in patient care in general practice.
The introduction of polyclinics or GP-led health centres provoked strong responses from readers and some of these are outlined Table 1.

[[Tab 1_survey]]

Health visitors
The results from the last survey showed that morale was very low among health visitors and this makes the new survey results interesting reading. There has been little change in the way that health visitors feel in terms of disillusionment about their career and the future of the profession, with 31% stating that their morale is "very low" and the same proportion saying it was "quite low" – almost exactly matching last year's results. This coincides with the current high-profile shortage of health visitors, which led Conservative leader David Cameron last year to pledge that his party would more than double the number of
health visitors.2
This also coincides with the decision taken by  Barking and Dagenham Primary Care Trust (PCT) to appoint 24 more fulltime specialist community nurses. This was hailed as "a massive leap forward in public health for the East London borough" by Unite the Union, the largest union in the country. The union also said that the decision goes a long way to reverse the health visitor vacancy rate running at 45% in one of the capital's most deprived boroughs.

Cheryll Adams, Unite/CPHVA Professional Officer for Research and Development, was not surprised by the latest Nursing in Practice survey results, and had concerns over the impact of such low morale. "If staff are feeling like this it must be affecting their ability to provide a good service," she said.

"There have now been many such surveys giving the same results. Children's health must be suffering and this will have long-term cost implications for the NHS. The long-term impact may by increased levels of obesity, coronary heart disease and mental illness. It's time that such figures are taken seriously by
PCT managers."

Despite this apparent doom and gloom, there were some positive results, indicating that many health visitors are finding fulfilment in their work and enjoying their job. For example, in response to a question about work-related stress, in last year's survey, 35% felt that their levels of stress were "a lot and unmanageable." This compares to 25% of respondents in 2009
(see Table 2).

[[Tab 2_survey]]
Forty-eight percent of health visitors said that they would not recommend a career in the primary care sector. While this clearly reflects disillusionment, it is nonetheless an improvement on the 60% who felt this way a year ago.

A health visitor from Cheshire stated: "We need more stability, otherwise it can be an interesting part of nursing." Another, from Kent, commented: "I still love this job in spite of the stresses".

Primary and community care nurses
In marked contrast to the results from many health visitors, most primary and community care nurses said their morale was, in fact, fairly high.

Marilyn Eveleigh, Consultant Editor of Nursing in Practice, said: "Staff morale is hugely important at this time. In a recession, there is an increase in stress, depression, self-harm and illness. It will test the skills and energy of primary care nurses. I am concerned the personal and economic worries of nurses do not add to these professional challenges."

The largest group (41%) said that their morale was moderate, with 31% answering that their morale was "quite high". This suggests that, despite the economic climate, primary care nurses in general feel fairly contented with their lot career-wise. One respondent said: "I am currently undertaking a postgraduate diploma in district nursing and the enthusiasm levels are high. I am however, unlikely to get a job at the end of it, which puts a dampener on things." Other comments included:

  • "Good employer, enjoyable work, good work/life balance" – practice nurse, Essex.
  • "I am doing a job I love with good supportive management, clinical colleagues and admin support" – nurse practitioner, Staffordshire.
  • "Supportive employers, good job prospects" – practice nurse, West Yorkshire.

In answer to the question "What one thing would you like to see that would improve your working life?",  many people said that they would prefer less admin and paperwork. Comments included:
  "Extra and consistent clerical support. The filing system is the first to go when colleagues are under stress but this adds to the stress as it takes longer to find anything. We don't need a band 4 to file! I've suggested keeping the higher bands for more sensitive work like letters and employing a lower band to file" - health visitor, Cambridge.

The latest survey also included comments from professionals who were looking at their job options for varied reasons. A practice nurse in Scotland said: "I don't think I want to work under this pressure for the next 10 years, I think I'll try nurse teaching." Similarly, a tissue viability nurse from Derbyshire commented: "It is not nursing as it used to be. Less patient contact, more administration work. More stress, staff taking more time off sick or leaving and leaving us short-staffed."

However, to end on a positive note, 80% of respondents would recommend a career in nursing in the primary care sector and this reflects the general mood of the survey results that nursing can be a rewarding career despite the challenges. There were many comments from people praising their workplace, teams and managers, and these are indicative of the reasons why you stay loyal to the nursing profession:

  •    "It's the best job in the world, when you are allowed to do it!" – practice nurse, East Sussex.
  •    "It is still very rewarding to support patients through frightening and traumatic times, and to feel like you can make a difference" – practice nurse, Suffolk.
  •    "I have been in practice nursing for 21 years and like the variety and challenges it brings" – practice nurse, Suffolk.
  •    'There is still a great sense of satisfaction to be had in primary care, and continuity of care that secondary care settings rarely provide" - practice nurse, Leeds.

1. Polyclinics will employ "three times more nurses than GPs. Management in Practice, 2008. Available from:
2. BBC News website. Cameron vows more health visitors. BBC, 2008. Available from: