Nurses account for 50% of the global workforce (WHO 2018) and are central to care provision. So with unprecedented demand for healthcare arising from people living longer with multiple physical and mental health conditions, the contribution of RNs is vital (RCN 2018). However the UK Nursing and Midwifery Council (NMC) reported 1678 fewer nurses and midwives on the NMC register in September 2016 than 2015 with more nurses leaving the register than joining it (NMC 2017). Such high nurse turnover and absences quickly affect quality of care outcomes (Daouk-Oyry et al. 2014).
Recent surveys suggest that apart from changing personal circumstances, the top reason for leaving the profession is working conditions, including staffing levels, high workload and disillusionment with care quality provided to patients (NMC 2017). The strongest supported determinants of turnover include stress and burnout, job satisfaction and to a lesser degree, commitment with supervisor support being the most supported determinant for retention (Halter et al, 2017). Whilst a large body of evidence exists concerning factors and interventions linked to nurse retention, the quality of this evidence is limited (Halter et al. 2017).
Aim: This paper reports on the findings from the first of two linked collaborative projects involving a UK University and a large health service provider to explore TRACS, an innovative evidence-based model for improving nurse retention. The model comprises five key elements known to influence nurses’ decisions to leave or stay in the profession: Transition, Resilience, Authentic leadership, Commitment and Support.
Methods: A mixed method approach was employed and ethics approval gained from the university involved and the Health Research Authority (HRA). Initially organisational data relating to two clinical directorates in one acute hospital (Older Person’s Medicine (OPM) and Surgical) were collated to provide an overview of RN staffing levels. These data were derived from Human Resources records (October 2016-September 2017) of sickness, absence and staff turnover. To gain a better understanding of the situation for RNs within the directorates, RNs from OPM (n=147) and the Surgical (n=131) directorates were asked to complete the Practice Environment Scale-Nursing Workforce Inventory (PES-NWI) (Lake 2002) and Maslach Burnout Inventory (MBI) (Maslach et al 1996) instruments.
Open staff consultation events with RNs from across the organisation (n=21) were also held to identify areas for potential intervention. Thematic content analysis informed the development of an interactive web portal to support nurse retention.
Results: Human Resources data revealed that OPM has significantly higher levels of RN staff turnover (p = 0.006) and vacant posts (p < 0.001) than the surgical directorate over the year October 2016 to September 2017. The most notable difference was in the vacant posts, with a median of 20% of the full time equivalent posts the hospital had funded within OPM unfilled compared with 7% in the Surgical directorate. There was no difference between the directorates in terms of the number of RN absences due to sickness.
A total of 122 RN participants responded to the combined PES-NWI and MBI questionnaires comprising a response rate of 39.5% from OPM and 48.8% from Surgical. The PES-NWI composite and 5 subscale scores were very similar across both directorates, with the mean (SD) Composite Score (out of 20) for OPM at 13.71 (2.61) compared to 13.63 (1.68) for Surgical. Within OPM, respondents scored highest (median score > 3/4) for the importance of supportive managers, teamwork, and development through preceptorship. The most negative impact on work life was lack of staff (median score ≤ 2/4). There were no differences between the directorates for Emotional Exhaustion, Depersonalisation or Personal Accomplishment as measured by the MBI.
The staff consultation exercise was used to engage nurses across the Trust in the topic and explore reasons people decide to stay and leave. Both this and the survey data, supported much of the literature on nurse retention; the main factors that influenced intent to stay included working in an environment where staff feel valued and empowered, with strong nursing leadership and support in their role through education and development, person-centred appraisal and support for wellbeing. Where staff are more negative about their work experience and therefore at risk of leaving feel that there is insufficient resources both staff and equipment, leading to a task centred approach, compounded by poor nurse leadership.
This feedback was used to inform the design an interactive ‘one stop shop’ web portal based on the TRACS model of key information and resources for RNs, available via any internet enabled device including mobile phones. A future linked project will use the reported data for comparative purposes to evaluate the portal and other interventions.
Conclusion: Nurse shortages are a global concern for health service and nurse education providers. Collaborative strategies that focus on recruitment, retention and transition are important in a highly competitive employment market. The co-created TRACS model focuses attention on this critical issue and will be of interest to an international audience.