Nurses employed in the UK today are working in a pressurised service that is struggling to meet health and social care demands; this is made worse by high vacancy and staff turnover rates. NHS workforce statistics report a worrying picture, with 34 000 UK nursing vacancies, equating to one in 10 vacant posts (The King's Fund, 2021a; NHS Digital, 2021), and 28% of nurses and health visitors in England leaving the NHS within the first 3 years of service (The King's Fund, 2021a).
The nursing profession is also contending with high attrition rates on preregistration nursing courses. For example, 24% of those starting a nursing degree either do not graduate or do not graduate within the expected time frame (Buchan et al, 2019). On a positive note, in February 2021, the Universities and Colleges Admissions Service (2021) recorded 60 130 UK university applications to study nursing, an increase of 32% on the previous year. The increasing number of students applying for nursing has been attributed to people being more aware of what nursing entails (BBC News, 2021).
Although a boost in nursing application numbers is encouraging, the impact of increased numbers of learners on existing registrants must be acknowledged. Existing registrants may need to supervise more students and complete extra student sign-off competencies and performance reviews, amid increasing service demands that need to be planned for in the future (Royal College of Nursing (RCN), 2018; Maguire, 2021).
Government health and social care bodies are developing a national database of clinical placements that will take into account national and local capacity to support student nurse placements in the future (RCN, 2020a). The positive impact of having increased numbers of students in clinical environments also needs to be recognised. Increasing the number of students may reduce the risk of adverse patient events (Williamson et al, 2020), contribute to the development of a learning organisation and enable mentors to reflect on their own skills (Uren and Shepherd, 2006). Hosting student placements in clinical environments also gives practice supervisors and managers an opportunity to inspire students to apply for future jobs in their clinical area.
Workforce projections show a similar picture and highlight an urgent need to address nursing workforce issues. It is forecasted that, in 10 years' time, the NHS will have a shortage of 108 000 nurses and will require 5000 more students to start each year by 2021 to meet future workforce demands (Beech et al, 2019).
To tackle nurse shortages, the 2019 Conservative government manifesto pledged to secure 50 000 more nurses for the NHS by 2024–2025 (Conservative and Unionist Party, 2019), through employing 31 000 newly qualified or recruited nurses (such as international nurses and those returning to practice) and improving nurse retention (Beech et al, 2019; Health Foundation, 2019; The King's Fund, 2021b).
Since February 2020, the profession has had to deal with service reconfiguration and redeployment to support the NHS clinical delivery plan for COVID-19 (NHS England/NHS Improvement, 2020a). In the wake of COVID-19, waiting times for routine care have increased, with one in 12 people on NHS waiting lists having been on them for more than a year (The King's Fund, 2021b). It is evident that the additional COVID-related workload has placed a strain on an already understaffed workforce, which has had a detrimental effect on the wellbeing and mental health of UK healthcare workers (Gilleen et al, 2021). Accessible wellbeing support will be required in the future to prevent nurses leaving the profession from work-related stress.
In the light of current and projected workforce data, it is important to evaluate nurses' experiences in the workplace and their career plans to inform local and national retention strategies. Findings from the most recent RCN survey examining nurses' experiences during COVID-19 reported that 36% of 42 000 nursing respondents were thinking of leaving the profession (RCN, 2020b). Although the COVID pandemic has exacerbated work-related stress, similar views have been longstanding within the profession. A previous RCN employment survey in 2017, for example, reported that only 41% of the 7720 nurse respondents would recommend nursing as a career, and 63% felt they were under too much pressure at work (Institute of Employment Studies, 2017). Significant change is required to encourage the current and future nursing workforce to stay, with nurse retention initiatives an important aspect of this.
The People Plan (NHS England/NHS Improvement and Health Education England (HEE), 2020) provides practical advice on specific initiatives to improve staff retention such as: developing a retention strategy; supporting new starters; enabling flexible working; career planning; and staff engagement. To help facilitate staff engagement, NHS Employers (2022) offers guidance relating to the types of staff conversations employers may have during an individual's career such as: recruitment; post-offer; induction; stay discussions; ‘itchy feet’ conversations; and exit discussions.
Similarly, the four-nation review by The King's Fund, The Courage of Compassion: Supporting Nurses and Midwives to Deliver High-Quality Care (West et al, 2020), provides recommendations to transform nurses' and midwives' workplaces to enable them to thrive and feel valued. Key interventions are identified to reduce staff stress and turnover, such as: flexible working to promote work-life balance; compassionate leadership to promote nurturing cultures; effective health and wellbeing support; supervision to enable staff to succeed; and cohesive teamworking to enable staff to feel they belong and are cared for at work (West et al, 2020). Supportive, cohesive teamworking is a key contributor to staff retention, as nurses report feeling demoralised or undervalued at work in national professional surveys (NHS England/NHS Improvement and HEE, 2020; Senek et al, 2020; Nursing and Midwifery Council (NMC), 2020).
Senek et al's (2020) UK survey, developed by the RCN, explored the levels of dissatisfaction and demoralisation across the nursing workforce as a predictor of intention to leave. The study concluded that more research was needed to investigate the relationship dynamics within healthcare teams and how the lack of support experienced by nurses impacts on their ability to provide safe, good-quality care.
Lack of research
Although nurse retention is a pressing issue, there is a lack of empirical UK research evaluating the impact of staff engagement and retention initiatives on retaining nurses. Literature reviews have focused on the retention of undergraduate nurses or early career nurses (Brook et al, 2019; Wray et al, 2021), and have identified a need for future studies to report retention outcome measures relative to interventions.
Several evaluative studies have presented proposals to promote nurse retention, such as: bespoke mentoring to retain overseas nurses (Kelly and Fowler, 2018); a nurse clinical fellowship programme to retain the current nursing workforce (Marsh et al, 2019); and career pathways to retain early career nurses working in gerontological services (Naughton et al, 2020).
These studies suggest initiatives will have a positive impact on nurse retention in the future. Local evaluative service reviews, such as the project presented in this article, may add insights into how staff engagement events may support nurse retention.
Implementation of Listening to Staff events
Aim and objectives
The service review aimed to:
- Deliver staff engagement Listening to Staff (L2S) events to examine nurses' perceptions of teamworking and support as well as their career plans
- Inform nurse retention strategies across acute care settings experiencing an increase in nurse leavers.
The project objectives were as follows:
- To examine nurses' perspectives of teamworking and support
- To establish nurses' future career plans
- To identify key areas for development to inform nurse retention action plans
- To deliver and evaluate nurse retention action plans.
Methods
L2S events were held over a 3-year period across 25 acute care settings in one division of an NHS hospital trust in England. A divisional working group was set up to lead the project and local governance structures were followed throughout the review. Following local trust authorisation, an email was sent to matrons explaining the project's aims and objectives as well as the risks and benefits. Events were timed according to service and staff needs, and posters to publicise them were disseminated by local managers in advance.
The methods used were intended to facilitate staff attendance by offering one-to-one or group conversations, with events held over several days across different shifts. Staff conversations were conducted by the divisional recruitment and retention (R&R) lead, who did not work in the clinical area.
Conversations were held in a closed room to maintain confidentiality and nurses' verbal consent was sought before every conversation. Attendance was optional, and staff were informed they did not have to answer any questions and could withdraw from the conversation at any time.
A semistructured, conversational approach was used focusing on four key areas:
- Staff feeling valued/undervalued
- Teamworking in the area
- Staff support
- Future career plans.
These broad areas reflected local exit interview data and key nursing concerns reported in national professional surveys, such as a perceived lack of support and feeling demoralised or undervalued (NHS England/NHS Improvement and HEE, 2020; NMC, 2020; Senek et al, 2020).
Opening questions started the conversation such as: ‘How do you feel about teamworking in your local area?’ or ‘What is your future career plan?’ Questions were further clarified, eg, ‘Could you explain what you mean by … ?’ During conversations, written notes were taken by the R&R lead. At the end of each L2S conversation, a summary of points was agreed with the person to confirm their feedback.
Participants were informed their narrative would be anonymised and only overall findings would be reported back to managers. Following staff conversations, any nurses who felt they were struggling in practice were offered an immediate development plan of support.
Data analysis
Content analysis was used to analyse narrative transcripts from conversations. The formation of codes and categories from descriptive patterns and frequencies informed the findings (Creswell and Creswell, 2018). Comparative narratives and codes were reviewed by the project team to reduce potential bias, using a decision trail as a checking process (Robson and McCartan, 2016). Analysed data were later summarised into key findings to inform managers' retention action plans.
Findings and actions
L2S events were conducted in a variety of acute care settings including: ambulatory; theatres; critical care; wards; and outpatient areas. A total of 576 nursing staff (including nursing support staff, such as nursing assistants and nurse associates) in a range of roles participated in conversations (Table 1).
Table 1. Participant roles
| Nurse role | Number taking part |
|---|---|
| Nursing assistants | 131 |
| Nursing associates | 30 |
| Staff nurse | 242 |
| Deputy sister/charge nurse | 135 |
| Sister/charge nurse | 34 |
| Deputy matron | 4 |
Attendance at events was high in most areas (70–80%) and, in three areas, 90% of nurses chose to participate. During the project, most registered nurses, nursing associates and nursing assistants chose to have a one-to-one conversation rather than a group discussion.
Findings were shared with the divisional working group, which informed decision-making throughout this project. Matrons and sisters/charge nurses were authorised to implement new nurse retention plans and actions, which were collaboratively agreed, monitored and evaluated by divisional and local teams. General findings were identified across all areas in the division, which included a need for more individualised career advice and career advisory sessions for all nursing roles. Example findings and actions are presented in Table 2.
Table 2. Findings and actions
| Key overall findings | Retention actions |
|---|---|
| Nurses across all roles requested more career advice |
|
| Nurses in all roles requested more awaydays/development days linked to their role |
|
| Staff nurses and deputy sisters/charge nurses requested more flexible rotas/flexible working (in areas where local managers had recently changed shift patterns) |
|
| Staff nurses requested more clinical education support in the clinical setting |
|
| Most nurses had positive perspectives of teamworking |
|
Additionally, each local area had specific areas for development, for example, one ward had a larger ageing demographic of nurses, some of whom were worried about using the electronic patient records system that was being implemented at the time. Managers were able to address nurses' learning needs with additional one-to-one digital support in the clinical area.
Evaluation
Impact on quantitative retention data
Comparing retention data before and after L2S events indicated that nursing turnover decreased from 18.9% in October 2017 to 10.2% in October 2020. Divisional vacancies also reduced from 11.9% in December 2017 to 9.8% in October 2020.
However, the authors acknowledge that nurse retention is nuanced and multifaceted. Turnover is affected by international recruitment, service and staff reconfigurations, the leadership style of a new manager and staff demographics. Without longitudinal feedback from staff themselves, only tentative conclusions can be drawn.
Discussion: the need for a multifaceted approach
It is evident from this service review that a multifaceted and individualised approach is required when evaluating retention plans and initiatives. Over the last 3 years, for example, L2S conversations identified 28 registered nurses intending to leave their role. The team was able to offer these individuals support with personal issues or find them an alternative role that suited their preferences to retain them in the organisation.
To accommodate staff requests, teamworking across the division reflected the compassionate, flexible and cohesive approach recommended by The King's Fund (West et al, 2020). Managers negotiated within divisional team meetings where best to place individuals to balance the needs of the service with those of an individual.
Overall, most nurses had positive perspectives of teamworking in their local area. Where nurses asked to move to another clinical area, this was to develop their skills and knowledge and to support their career progression, as opposed to poor teamwork or feeling unhappy in their current area.
Following the review, the divisional team continued to use collaborative team approaches and networks to maintain cohesive teamworking. Individuals who required additional support with a specific issue were offered local, divisional or human resources guidance appropriate to their needs.
The need for more career advice across all nursing roles was significant within this review and one-to-one and group careers advice sessions were offered to all staff. It was evident from nursing assistant conversations that many individuals were not aware of apprenticeship career pathways and development opportunities available in the organisation. Nursing assistant career sessions focused on increasing awareness relating to apprenticeship opportunities. The numbers of internal nursing assistants from the authors' division starting a trust nursing associate or nursing degree apprenticeship increased from seven in 2017 to 30 in 2020. These individuals were retained in post for the duration of their apprenticeship by having a clearly defined career pathway. Divisional R&R leads aim to align future roles across the trust for nursing apprentices as they near the end of their apprenticeship to retain them within the organisation.
It is evident that nursing turnover may be both a problem and a positive when it is associated with career progression and professional development opportunities. Nurses who are proactively supported with their career development may leave their role to pursue a professional or educational opportunity elsewhere. Nurse managers who encourage career development may therefore see an increase in their nursing turnover. In turn, study leave offered to staff remaining in the clinical area may need to be restricted until nursing vacancies are filled to ensure that service needs are met. Following this review, staff study days were held in smaller groups to promote attendance in areas where nursing turnover had increased.
Within this review, it was noted that the majority of nursing assistants returned to work with the team that had supported their nursing apprenticeship. These staff wished to pursue their career goals with the same manager or clinical educator guiding their development. It was evident that several nursing associates felt a sense of loyalty to a team that had already supported them. For example, one nursing associate stated:
‘The manager and the team were so good supporting me on my course. I want to support her and give something back to our ward. I want to keep going up the career ladder to become a registered nurse too. I feel like they will keep supporting me here as the team works well together.’
Similarly, the majority of registered nurses who declared their intent to stay for a ‘couple of years’ in an area stated that this was because their line manager had supported an application for a postregistration course or encouraged their career progression.
Career advancement opportunities have also been found by researchers to be a key factor influencing nurse retention (Szeremeta and Shamash, 2016; Boulton and Beer, 2018; NHS Employers, 2020; Marufu et al, 2021), which reflects the findings from this review. Although nurse turnover can be a problem, employers who provide opportunities for professional development and career progression may also position themselves competitively when recruiting staff (Szeremeta and Shamash, 2016; Health Foundation, 2019; Aeschbacher and Addor, 2021).
‘More staff development across roles’ was another significant finding. The divisional education lead and clinical educators went on to deliver bi-annual divisional awaydays aimed at a range of staff groups. Positive verbal and written evaluations from awaydays provided evidence of staff feeling valued and personal issues being resolved.
One deputy sister said: ‘I feel valued, and I can share ideas with other band 6s who know how I feel.’ Attendance at awaydays helped staff to feel supported and valued, which supported them in their current role, making it more likely that they would stay in the organisation.
National initiatives, such as the HEE RePAIR project, support the use of clinical educator roles to reduce preregistration attrition and improve staff retention (HEE, 2018). The HEE (2018) RePAIR toolkit promotes the sharing of good practice, buddy schemes and clinical practice educator posts, structured preceptorship and staff wellbeing. To address the need for more clinical education to support new starters in practice, a divisional working group set out to review clinical educator roles and the numbers of educators in the division increased from 12 to 17 (Lanada and Forde-Johnston, 2021).
UK clinical nurse educators (CNEs) are usually employed by NHS organisations to ensure staff receive essential clinical support, education and training (Sprinks, 2015). Research evaluating the impact of CNE roles is limited and the role is subject to a variety of interpretations (Sprinks, 2015; Lanada and Forde-Johnston, 2021). However, available evidence suggests that the CNE role is valued by students and staff, having a positive effect on their clinical experiences and learning (Jowett and McMullan, 2007; Matthew-Maich et al, 2015; Hampson et al, 2017; Lanada and Forde-Johnston, 2021).
There is also evidence that CNE roles promote research-based clinical practice and professional development through lifelong learning (Milner et al, 2005; Petrova and Camilleri, 2015). In the authors' local evaluation of CNE roles, divisional staff nurse questionnaires showed an increase in new starter satisfaction in areas that had increased their numbers of clinical educators, raising the chance of retaining new starter nurses (Lanada and Forde-Johnston, 2021).
The need for more flexible rotas to promote a better work-life balance when local shift patterns had been changed was also a key finding. The findings here align with national data, as nurses often cite a lack of work-life balance and/or a need for more flexible working as reasons for leaving the profession (NHS England/NHS Improvement, 2020b). Two and a half times more nurses in England gave work-life balance as a reason for leaving at the start of 2018-19 than in 2011-12 (Beech et al, 2019).
Following the L2S event, the matron and the local manager reviewed individual staff rotas and were able to accommodate more flexible working patterns wherever possible. Alternatively, the R&R lead offered a position in another area with more suitable shift patterns (eg outpatients) to retain them in the organisation.
The trust is piloting a staff self-rostering system to meet employee needs. The evidence base examining the impact of self-rostering on the nurse and/or organisation suggests a variety of both positive and negative outcomes (Koning, 2014; Wynendaele et al, 2021). Several studies have found that self-rostering had positive effects, including: improving work-life balance among nurses (Richmond and Greenhill, 2003; Wortley and Grierson-Hill, 2003; Pryce et al, 2006); giving staff more flexibility and control over their hours (Bailyn et al, 2007; Ásgeirsson, 2014; Drake, 2014a); improving staff morale and retention (Rondeau and Wagar, 2016; Hainey, 2021); and reducing the time spent by head nurses on producing rosters (Miller, 1984; Bischof, 1992). Drawbacks relating to the use of self-rostering in practice include: managers lacking the training to facilitate self-rostering and having to spend time dealing with individuals' shift preferences (Drake, 2014b); nurses with better negotiation skills obtaining better shifts (Rönnberg and Larsson, 2010); overstaffing or understaffing when there is an inability to align nurses' preferences with service requirements (Bailyn et al, 2007); and a lack of continuity in care for patients and colleagues (Nabe-Nielsen et al, 2012). The variety of staff and organisational experiences surrounding self-rostering needs to be further examined nationally and the evaluation of self-rostering for nurses within the authors' trust is ongoing.
Future national priorities
It is evident that safe nurse staffing standards and the prevention of staff burnout need to be prioritised across the NHS and health and social care in the future (House of Commons Health and Social Care Committee, 2021; RCN, 2021).
A recent report from the Health and Social Care Select Committee on workforce burnout and resilience in the NHS suggests that both will be achieved through better workforce planning and compassionate leadership. Compassionate leadership was highlighted during this inquiry as an essential factor in encouraging positive workplace cultures, where staff feel listened to, are supported to speak up and are professionally developed (House of Commons Health and Social Care Committee, 2021).
The service review described here suggests that L2S events align with this national nursing agenda, as nurses' perceptions of teamworking and support as well as their career plans are listened to by nurse leaders. Data from events inform retention strategies and staff professional development plans to target additional support where it is needed, which helps to retain nurses and support our future workforce.
Conclusion
The L2S project demonstrates that valuable insights may be gained from a staff engagement initiative accessible to all nursing staff. The findings from staff conversations informed managers' retention plans, and pre-post evaluative data suggest improvements in nursing turnover and vacancy rates.
It is evident that nurse retention is multifaceted, and staff retention initiatives need to take an individualised approach to retain nurses in an organisation.
A collaborative team approach is also important as retention issues may affect several individuals or areas in an organisation. The authors' divisional team were able to support local managers to deliver retention actions and facilitate larger retention initiatives. All staff should have a voice that is listened to by line managers wherever they work, and nurse leaders have a responsibility to act on this feedback.
Evaluating the impact of deliverable actions to promote nurse retention can only improve the chance of retaining the existing workforce. We need to ‘listen’ to staff and ‘act’ now, as the future of the nursing profession depends on it.
KEY POINTS
- Retaining the current nursing workforce is a priority for health and social care managers
- There is a lack of research examining the impact of staff engagement initiatives and retention strategies on nurse retention across the UK
- Examining nurses' perceptions of teamworking and support as well as their career plans provides data that may help retain a nursing workforce
- Staff retention is multifaceted and a local, individualised approach towards staff engagement is needed to improve nurse retention
CPD reflective questions
- What do you think the impact of retention has on the nursing profession? Consider national policies and workforce data relating to staffing shortages. Reflect on how this data relates to your experiences of staffing in practice
- What types of staff engagement conversations could an employer or manager offer you? What types of staff engagement conversations does your organisation offer? Reflect on how you could prepare for these conversations to ensure that you gain the most benefit out of them
- How could you help support staff retention in your current role? Identify three key actions that you could implement to support staff retention where you work. Reflect on how you would achieve and evaluate these future actions