Although nurses account for more than half of the world's healthcare workers, with approximately 28 million in the nursing profession worldwide, there will be a global shortfall of 5.9 million nurses according to the World Health Organization's (WHO) (2020)report on the state of nursing globally. These data do not reflect the impact of the pandemic, which has further highlighted the need for more nurses and midwives.
In 2019, the WHO said that 2020 would be a year to recognise the global contributions nurses and midwives make to improve the health of patients around the world (WHO, 2019). However, with efforts being made to increase the profile of nurses and midwives globally, work is still required to ensure that these important staff members are retained.
With an increase in demand for nursing services worldwide, healthcare organisations need to manage their nursing resources strategically to meet future demand (Oulton, 2006). Retaining high-performing nurses is difficult at best and, throughout the course of the pandemic, the need has been exacerbated in terms of numbers and types of nursing specialties needed (Spurlock, 2020). When a nurse leaves an organisation, replacing this staff member has cost implications, including those of recruitment and orientation of their replacement, as well as the indirect cost of the loss of organisational knowledge (Jones, 2004).
The onus is therefore on healthcare systems to implement measures to improve retention. Various strategies have been proposed to achieve this, including leadership (Kleinman, 2004), development opportunities (Sawatzky and Enns, 2012; Szeremeta and Shamash, 2016) and flexible working (Gould and Fontenla, 2006; Duffield et al, 2011). Recognition of staff has also emerged as a strategy associated with increased job satisfaction and a decrease in intention to leave (Duffield et al, 2011).
The DAISY Award was established in the USA by the DAISY Foundation in memory of J Patrick Barnes who died aged 33 years of an autoimmune disease; DAISY stands for disease attacking the immune system (DAISY Foundation, 2022). The Barnes family were awestruck by the care and compassion Patrick received from the nurses who looked after him, so they created the international award to say thank you to nurses and midwives. The award was designed to celebrate the unique and fundamental nursing qualities that are not in a nurse's job description but that make a difference to the patient and family experience (Barnes et al, 2016).
The DAISY Award aims to provide meaningful recognition, which is defined in the literature as ‘a powerful form of positive feedback, meaningful recognition [that] acknowledges how a person's actions affect the life of another, is relevant to the recipient, and is equivalent to his or her contribution’ (Barnes and Lefton, 2013: 115). The difference between meaningful recognition and other forms of positive feedback is the longevity of the effect, as meaningful recognition can resonate throughout a person's life.
There is a strong body of evidence showing that meaningful recognition promotes a healthy work environment, which in turn leads to greater nurse engagement and retention (Lefton, 2012). Recognising and celebrating compassionate and expert nursing care with the DAISY Award may counter the negative impacts of the work environment and enhance the positive (Kelly and Lefton, 2017).
The DAISY Award was introduced in an inner-city, tertiary hospital in the UK in 2019 to show how much patients, carers and colleagues supported, valued and respected the work of our nursing and midwifery workforce. By October 2019, 23 nurses and midwives had received the award. The aim of this study was to evaluate the hospital's DAISY Award programme as a potential retention initiative.
Methods
Setting
This research adopted a qualitative policy approach that explored the insights and perceptions of participants and the deeper meanings they attached to their situation. By using a qualitative approach, underlying attitudes, motivations and feelings, which provided the contextual basis for the ideas expressed, could be examined.
Eligible participants were registered nurses or midwives working at the hospital who had won a DAISY Award or had been nominated for one, or were a patient or family member who had nominated a staff member. This ensured that we evaluated the DAISY Award from three perspectives.
The Health Research Authority's research ethics service determined that the project was an evaluation and therefore exempt from the need to obtain approval from the committee or the authority (http://www.hra-decisiontools.org.uk/research).
Eligible participants were contacted by the clinical lead for the DAISY Award (WB) by email, which included information about the evaluation and a participant information sheet. These emails were sent on multiple occasions at different time points in the day. If participants were interested, they were asked to contact the researcher (LW) via email.
Data collection
Data were collected through semistructured interviews conducted through Microsoft Teams between November 2020 and May 2021.
Interviews were conducted virtually because of COVID-19 pandemic restrictions. The interview guide was developed based on a literature review undertaken by one of the authors (LW) and discussion within the evaluation team. It was reviewed for completion by the recruitment and retention team.
Questions focused on motivations to nominate nurses, emotional responses to being nominated and opinions on intent to remain within the organisation.
The interviews were conducted at a mutually convenient time by one member of the team (LW). Consent was gained at the beginning of each interview by reading out a preset statement and, if the participant agreed to this, the interview continued. If they did not consent, the interview was terminated. The interviews took 30–60 minutes.
Data analysis
Data were analysed using framework analysis, which is a structured method of analysis conducted over five stages: familiarisation, indexing, charting, mapping and interpretation (Ritchie and Spencer, 1994). This approach identifies commonalities and differences in qualitative data before focusing on relationships between different parts of the data, thereby seeking to draw descriptive conclusions clustered around themes (Gale et al, 2013).
When the interview recordings were completed, they were uploaded to an online transcription service and deleted when the transcript was confirmed as correct. All information remained anonymous so no participant could be identified.
Transcripts were coded and an analytical framework was developed to enable the responses of the three groups—winner, nominees and nominators—to be compared. Codes were grouped into categories as themes emerged.
Findings
Twelve people participated in the evaluation: four winners, four nominees and four nominators (two patients and two family members).
Four major themes emerged from participant responses: awareness of the DAISY Award, nomination process, winner benefits and impact on retention.
DAISY Award awareness
Participants' opinions were mixed as to whether the DAISY Award had sufficient publicity, but both winners and nominees reported that they had never heard of the award before their nomination.
Some of the international staff had previously worked in the Philippines where the award is well known, so, although staff were aware of it in general, they did not know that it had been adopted in the tertiary hospital:
‘We really need to raise the profile of the DAISY Award.’
Some participants had seen posters around the hospital but it also appeared there were discrepancies between hospital sites. It was reported there was much less advertising within one part of the hospital than at another site and even nominators reported the advertising was sparse:
‘I'm a frequent visitor to the hospital. I've been an inpatient several times and, at one point, was coming to the outpatient unit every day but it's not something particularly advertised about. I've never seen it—it's not reached my eyes.’
With the COVID-19 pandemic, the awards were given less publicity and the footfall of visitors was also dramatically reduced; in addition, some posters and boxes for posting nominations were removed:
‘I think it was obvious when it was first launched but, with COVID, all the unnecessary posters have been taken down due to infection control and it went to the back of the queue in terms of signage and priority.’
With a new visitor policy, there were opportunities for patients and family members to be informed of the award and the nomination process. COVID-19 was tough on all health professionals and nominators noted that team rather than individual recognition was at the forefront of their minds:
‘I think that's why a lot of people didn't use the DAISY Award during COVID – because it's very much about single recognition.’
The award ceremony was a fantastic way to raise awareness about it, but most winners and nominees felt that the celebrations were short lived:
‘I would have liked a bit more recognition, I felt it was a bit restrained. For me, it was huge and then it just felt a bit muted.’
All winners felt proud of their award and felt ‘the story should be shared a bit more’:
‘Maybe it could have gone on the intranet. I felt it was only celebrated for a short time, only really that day.’
From the nominators' point of view, they felt that all nominees should be recognised in all hospital communications, not just the winners.
Nomination process
The nomination process relied on patients, families and healthcare professions being aware of the awards and making the nomination.
This process moved from posting completed paper nomination forms in boxes in designated areas to an online-only submission system. The reduction in paper leaflets and posters lowered awareness of the award, so it depended on nurses and midwives signposting patients and families to it, which they were anxious about doing:
‘You never think, “oh I've been excellent today”, and hand them the leaflet thinking, “please nominate me”.’
One of the main concerns raised was that the move to online-only nomination could potentially be a barrier to nominations for patients and families:
‘Quite a lot of our patients don't have internet access or are unable to use technology due to their impairments.’
Finally, nominators said that they were uncertain whether their nomination had been received. They felt that it would be helpful to receive an automated email to confirm that it had been received safely.
‘I didn't hear anything back after my nomination until I heard from you for your research.’
The consensus among nominators was that they would have liked an opportunity to nominate more often and some were disappointed when their nominees did not win. There were suggestions around making the award more frequent so that more people could win one. However, the winners generally felt that part of the importance of winning the award was being among only a handful of those who achieved this each year.
Winner benefits
The winner receives a standardised award kit, benefits and other opportunities, including a sculpture, pin, certificate, a DAISY honouree logo to add to their email signature, and eligibility for a reduced tuition rate at Chamberlain University College of Nursing, Illinois, USA. However, every nominator who participated in the evaluation felt there should be a financial aspect to the DAISY Award, even if it had small monetary value, to show appreciation for the staff member:
‘I would like there to be a reward too. Or maybe a voucher they could pick from so they could buy something and, every time they looked at it, it reminded them of their DAISY Award.’
Although positive remarks were made about the email signature associated with winning the DAISY Award, it was not often used. It was reported that ‘the email signature is very big and can be quite difficult to attach to emails’ which was a shame as many winners reported that they ‘really liked the email signature, it's a bit of a talking point’. Formatting could be difficult: ‘I do have to crop it every time.’
Impact on retention
The final theme related to the impact adopting the award had on retention. Overall, feedback towards the hospital was very positive. All the nurses and midwives who were nominated or had won felt valued and supported. All of the nominees expressed the importance of being nominated:
‘It's like being nominated for a BAFTA—it gives you that status symbol and a great feeling.’
Winners and nominees highlighted the importance of value and recognition as a mechanism for retention:
‘Such a nice feeling when somebody recognises you for the work you have done, even though it's what you do on a regular basis because it's your job.’
Discussion
In summary, four key themes emerge from the interviews including awareness of the award, the nomination process, winner benefits and impact on retention.
The authors' hospital was the first in the UK to use the DAISY Award potentially as a mechanism to improve staff retention, and this is the first evaluation of the award itself. At the time of publication, this is the only known study to evaluate the experience of nurses and midwives of being nominated or winning the DAISY Award, and its implications for the value of recognition as a mechanism of retaining them in employment.
A body of evidence supports the link between meaningful recognition and a healthy work environment, both of which help reduce compassion fatigue (Kelly et al, 2015; Kelly and Lefton, 2017). This indicates that meaningful recognition and a healthy work environment contribute to improving retention (Pierce and Sweeney, 2021); however, there is limited evidence to suggest a direct link between meaningful recognition and staff retention.
There is also limited evidence on the perceptions of the value of the DAISY Award and its impact on staff retention. Lefton (2012: 337) suggested that meaningful recognition in the form of the DAISY Award helped nurses to recognise the importance of their contributions and empower them to shift their ‘I was just doing my job mentality to embracing the extraordinary nature of nursing's work and profession’. The power of meaningful recognition is evident in the proliferation of hospitals adopting the DAISY Award; however, they are employing the scheme without measuring its impact on retention and are focusing on the subjective experiences of those involved.
Through meaningful recognition, nurses are empowered to acknowledge the lives they touch and reconnect with the reason they became nurses. Although Lefton's (2012) evaluation was limited to participants in organisations already using the DAISY Award, these organisations are aware that there could be differences in the meaningful recognition felt between nurses in places that do or do not have the DAISY Award.
Furthermore, a study of compassion satisfaction and compassion fatigue in critical care nurses across 24 hospitals found that not only did receiving the DAISY Award improve compassion satisfaction but also that being nominated for the DAISY Award led to these nurses feeling greater satisfaction than those who had not received such recognition (Kelly and Lefton, 2017). Within the current study, both nominees and nominators recognised the value of being nominated, which aligns with the Kelly and Lefton (2017) study. Although winning the award has advantages, being nominated also has many positives attached to it.
Limitations
There were limitations to this evaluation. The small sample size may not be representative of the nurses and midwives who were nominated and won. Recruitment took place during the COVID-19 pandemic when many nurses were redeployed to other care environments. There could have been a reluctance to participate in a work-related study in non-work time.
Participants were DAISY Award winners or nominees and the study may have appealed to winners or nominees who had had a positive experience of the award.
Despite these limitations, this is the first evaluation of the DAISY Awards from the perspective of nominees, nominators and winners.
Conclusion
Being nominated for or winning a DAISY Award has a positive impact on staff feelings towards their role and the hospital. It would be interesting to see how this relates to workforce data on nurse retention and whether these feelings of having a positive impact translate into retention. However, it would be difficult to assess this during the pandemic because other factors are influencing nurses' intention to remain in the profession.
While this was a small evaluation of the DAISY Award in a single organisation, the value of adopting this scheme for recognising nurses' contributions to patient care merits further investigation.
The results of the evaluation were presented to the senior nursing and midwifery leadership team before the pandemic, which generated widespread discussion on how to improve awareness of the award. Because of restrictions in the first two waves of the pandemic in 2020, the DAISY Award was suspended at the authors' trust; however, it was deemed important so it has been reinstated to boost nursing and midwifery morale.
The restrictions on paper and leaflets as part of infection prevention and control measures led to the application process moving to an electronic nomination system. This was done through a QR code, which made it easy to access the application forms. The benefit of this was noted through an increase in patient and family applications in the 2021 nominations. Further changes to increase awareness and raise the profile of nominees and winners are planned for the 2022 DAISY awards.
KEY POINTS
- During a period of global nurse shortages, healthcare organisations need to focus on strategies to retain their existing nursing workforce
- Meaningful recognition makes a workforce feel valued and improves staff retention
- This is the first evaluation of the DAISY Award in the UK; the award was launched in the USA to recognise the skill and compassion that nurses provide to patients and their families
- The DAISY Awards are viewed positively and there is a need to raise awareness of them across the NHS
CPD reflective questions
- How does your organisation promote nursing retention?
- What would make you feel valued by your organisation?
- How do you make your team members feel valued?