Many registered nurses in the UK work in the social care sector in independent care homes and nursing homes. This article explores the challenges related to providing nursing care for adults in care homes, issues arising for nurses and nursing in the social care sector, and providing a career pathway for nurses in the social care sector. Steps need to be taken to ensure that cooperation, collaboration and leadership in nursing in the social care sector is recognised and that appropriate representation of nurses in social care takes place at national level.
In the UK, approximately 500 000 people live in care homes, with or without nursing, and more than 50 000 nurses are working in adult social care, which is about 7% of the total number of registered nurses in the UK. The majority of these 50 000 are working in care/nursing homes (Skills for Care, 2013). In the UK the majority of nurses (80%) who work in adult social care are employed in registered care homes with nursing, which are regulated by the Care Quality Commission (CQC); the remaining 20% work in either CQC-registered non-residential services or in residential homes that are not registered with the CQC (Skills for Care, 2013). Registered nurses working in adult social care are almost entirely employed in the independent sector.
More people are being admitted to care homes at an increasingly older age and in a more frail or ill condition. This means that the demand for nurses in adult social care will increase as the population ages and the number of older patients with long-term conditions increases (Christie + Co, 2015).
‘With the UK population growing older, living longer and suffering from an ever increasing range of conditions, the need for good quality care has never been higher.’
(Christie + Co, 2015: 2)
In addition, the white paper Caring for our Future: Reforming care and support (Department of Health, 2012) proposed radical changes in health and social care giving individuals more freedom to decide what kind of care they want in old age and where they want it to be. This move towards a person-centred approach to care (Department of Health, 2012) means that people will demand a high quality of care from adult social care nursing.
This article explores the challenges related to the care of adults in care homes, issues of recruitment, supply of nurses, nurse turnover, retention and registered nurse vacancies in the adult care sector and career pathways for nurses who work in the social care sector.
Care of adults in care homes—the issues
The reports from the inquiries into the Mid Staffordshire NHS Foundation Trust (Francis, 2013) and the Wintebourne View Care Home (Flynn, 2012) both highlighted a range of failings on the part of management and practitioners with regard to the care of patients/residents. Francis, in his executive summary, identified a number of particular failings related to patient care, including:
▪ A culture in the organisation that focused on the trust's business rather than on patients
▪ Standards and methods of measuring compliance that did not focus on the effect to patients of service
▪ Too much tolerance of poor standards and of risk to patients
▪ An attitude that monitoring, performance management or intervention was the responsibility of someone else. (Francis, 2013: 4)
These reports were followed by television documentaries about failures in care of older people in certain care homes (e.g. BBC, 2013).
In addition, the CQC found a significant variation in the quality of adult social care, with people in nursing homes tending to receive much poorer care than those living in non-nursing residential care homes (CQC, 2014). The CQC also recommended that more nurses need to be encouraged to work in the care home sector as there is currently a shortage of nurses in adult social care and in 2013–4, one in five nursing homes did not have enough staff on duty to ensure that residents received ‘good, safe care’ (CQC, 2014: 6).
The CQC also identified that good leadership was essential to people receiving high-quality care and that care provided by care homes where there was a registered manager in place was significantly better than that found in care homes where a registered manager had not been in place for 6 months or more (CQC, 2014). The CQC laid down challenges to care homes for ensuring safe, high-quality care (Box 1):
Nurse turnover and vacancies
The number of vacancies for registered nurses in adult social care according to the National Minimum Data Set for Social Care (NMDS-SC) is nearly 4000 (Skills for Care, 2013) although the Registered Nursing Home Association estimates this as 10 000 (Registered Nursing Home Association, 2014). The figure from the NMDS-SC represents a vacancy rate of 7.6%, a rate that is similar to other professions working in the sector. Many care home employers do not advertise for registered nurses, owing to a low number of applicants (Registered Nursing Home Association, 2014). However, the major issue for nursing in adult social care is nurse turnover. Turnover in adult social care nursing is higher than in the NHS, at 32.2%, compared with turnover of nurses in the NHS, which is 14% (Skills for Care, 2013). Turnover of nurses in adult social care is also higher than for other professions working in adult social care, such as occupational therapists (15.6%) and social workers (11.2%) (Skills for Care, 2013).
Turnover in adult social care nursing is also highest in regions where turnover in the NHS is lowest and, interestingly, the highest level of turnover is found in regions where the use of nurses from abroad is lowest. Regional variations in turnover exist as well with the north east of Scotland and London and the south east of England posing particular challenges for this sector (Skills for Care, 2013).
Demography, recruitment and supply of nurses
Over the past 10 years the number of registered nurses in the UK has fluctuated significantly. In 2007, a peak of 661 000 nurses on the professional register was reached. This was followed by a fall to 640 000 in 2009 which has been followed by a steady rise in numbers to 655,000 as at March 2015 (Nursing and Midwifery Council (NMC), data in response to Freedom of Information request, 31 March 2015). A number of factors have influenced the overall number of registered nurses over the past 10 years including the number of funded training places, government policy related to immigration from outside the UK, the economic situation and its influence on immigrants from within the UK, and an upward shift in the average age of retirement (Christie + Co, 2015)
Of the 655 000 registered nurses in the UK more than 310 000 work in the NHS (NMC, 2014) with 51 400 working in adult social care (Skills for Care, 2013). At a local level, the supply of nurses for adult social care is thought to come from nurses leaving the NHS looking for more flexible working, including part-time working patterns, and a perceived less stressful working environment. Demography shows that in adult social care, nurses are primarily over 40 years of age, mostly female, with a high proportion of part-time work patterns (Skills for Care, 2013). In addition, 38% of nurses in adult social care are from abroad (Registered Nursing Home Association, 2014). This figure is likely to increase. One issue raised by a number of organisations is how to attract younger nurses into adult social care. Factors that appear to deter newly-qualified nurses from working in this sector are a perceived lack of career progression, negative conceptions of the care home sector and the negative media reporting about working in care homes (Keogh, 2014). Further study needs to be undertaken into how to recruit younger permanent nursing staff into the sector, including encouraging nurses returning to practice to work in the sector and the need to create progressive nursing career pathways in care home settings. Of the 2031 nursing homes CQC inspected in 2012, 23% (467 inspections) were not meeting the CQC standard of having adequate nurse staffing levels, while 16% (603 inspections) of the 3771 residential care homes CQC inspected were not meeting the same CQC standard. In the NHS, 16% of 250 inspections of hospital services (40 inspections) failed to meet the standard (CQC, 2012)
The anticipated increased demand for nurses in adult social care will place increased pressure on the social care system in terms of finances and other resources. The reliance in this sector on a supply that is predicated on NHS workforce plans creates significant pressure on the ability to recruit UK trained nurses into care homes.
Recruitment of nurses from abroad into adult social care
Currently, 28% of nurses in the UK are from non-European Union countries (Skills for Care, 2013), which will become an issue when changes to the immigration laws come into effect in 2016. These changes mean that in order for skilled workers to be granted indefinite leave to remain (ILR) in the UK, they must have an annual income of £35 000. This will increase in 2018 to £38 000. This is far above the usual annual income for most nurses in the care sector (Royal College of Nursing (RCN), 2015). Nurses from non-European Union countries are allowed to stay in the UK for up to 6 years but they can remain indefinitely if they apply for and qualify for ILR. However, nurses who came to the UK before 2012 will be able to apply for ILR on the fifth anniversary of their arrival in the UK. Workers who have jobs that are on the Shortage Occupation List will be exempt from all of this. However, nursing is no longer on this list, despite the fact that the World Health Organization (2009) estimated that Europe as a whole is experiencing a shortage of nurses. A survey of NHS trusts found that 45% of them had recruited nurses from European Union countries in the previous year (NHS Employers, 2014). However, much of this recruitment has been as a result of the economic downturn across Europe. As the economy across Europe continues to improve, there are likely to be fewer nurses wanting to come to the UK. This, plus the previously mentioned forthcoming changes to immigration laws, means that in future migrants from abroad are less likely to be available in significant numbers. The independent care sector continues to lobby the government to put nurses on the Shortage Occupation List with little success.
Working patterns in the care home sector
Age, gender and working patterns of nurses in the care home sector, together with a high proportion of non-full time working patterns, suggest that nurses who are attracted to working in adult social care are seeking flexibility that may not be so available in the NHS. Frijters et al (2007) found in a study of nurses undertaken over 15 months that many nurses who left the NHS for adult social care settings ended up working more hours. However, they also suggested that the dissatisfaction with working hours in the NHS was more about shift patterns rather than working longer hours a week.
Additionally, despite high nurse turnover in adult social care in the UK, 45.6% of nurses in the sector have been in their posts since 2010 or earlier (RCN, 2012; Institute of Vocational Learning and Workforce Research (IVLWR), 2013). This suggests that many nurses are extremely dedicated to their roles and gain satisfaction from their contribution to residents' lives (Brodaty et al, 2013). The issue is about the need to recruit permanent staff who intend to remain working in adult social care for the long term. When this does not happen agency and bank nurses are used or existing permanent staff work extra hours.
Possible reasons for the issues for nursing in adult social care
In a survey of care home managers, the respondents indicated that care home nursing is not marketed as a desirable career path for nurses (IVLWR, 2013). They believed that more interaction with student nurses is needed, especially because of some of the negative press attention about the care home sector. Negative media coverage of nursing has had a detrimental effect on recruitment (Keogh, 2014). Professional organisations, such as Unison and the RCN continue to call on Health Education England to ensure commissioning of student nurses places accommodates the 60% of nurses employed outside the NHS. Currently, commissioning of student nurse places is based on projected workforce requirements within the NHS only.
The current commissioning model, in its failure to accommodate other sector workforce requirements, results in pressure across all sectors as all are fishing in the same inadequate pool. The previous coalition government failed to recognise this contribution to the situation that currently exists in this sector. This has resulted in:
▪ Poor supply of nurses in the care home sector
▪ Pressure from regulators/commissioners for suitable (but yet undefined) numbers of nurses in nursing homes
▪ Increasing demand on agency nurses
▪ Spiralling costs against a background of reducing fees from financially squeezed local authorities. (Skills for Care, 2013)
All of this has prompted intense scrutiny and media coverage of the care home sector.
In addition, there is a perceived lack of career development opportunities for nurses working in care homes with 19 of 29 respondents indicating that the provision of accredited courses for nurses would assist in the recruitment and retention of nurses (IVLWR, 2013). Pressure of working as the one registered nurse on duty in some care homes has also been identified as stressful. However, there is no evidence that the publication of the Francis Report (2013) has had a more adverse effect on recruitment in the social care sector than on recruitment into the NHS (Merrifield, 2014)
The above analysis of the issues and the literature surrounding the issues indicates that all organisations that provide adult social care need to address these if they are to adequately respond to the five key questions that the CQC poses when assessing the quality of services that each adult care home provides (Box 2).
This article has explored some of the current and future challenges for providing high-quality nursing care and leadership in care homes. Nursing in the social care sector needs to address issues of recruitment, supply of nurses, nurse turnover, retention and registered nurse vacancies in the adult care sector, as well as career pathways for nurses who work in this sector.
▪ A significant number of nurses in the UK work in nursing and care homes in the social care sector
▪ There are a number of issues and challenges for nursing in the social care sector related to supply and recruitment, nurse turnover and retention
▪ The current commissioning model for determining the number of nurses needed in the workforce does not take into account the numbers of nurses that will be needed in the social care sector
▪ The social care sector needs to address the challenges, including ensuring a robust career pathway for nurses in this sector
- BBC (2013) Panorama: Elderly Care: Condition Critical? Broadcast 17 June 2013
- Brodaty H, Draper B, Low LF (2013) Nursing home staff attitudes towards residents with dementia: strain and satisfaction. J Adv Nurs 44(6): 583–90 [CrossRef]
- Care Quality Commission (2012) The State of Health Care and Adult Social Care In England 2011/12. Care Quality Commission, London
- Care Quality Commission (2014) The State of Health Care and Adult Social Care In England 2013/14. Care Quality Commission, London
- Christie + Co (2015) The UK Nursing Workforce: Crisis or opportunity? Christie + Co, London