RETENTION OF NEWLY QUALIFIED NURSES IN THE NHS A Literature Review-Based Study and Change Management for the Retention of Newly Qualified Nurses in the NHS
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NEWLY QUALIFIED NURSES
Table Of Contents
Appendix 1: Summary of Literature Review Strategy 22
Appendix 2: Application of Cormacks’ Framework 23
Introduction and Background
Retention of registered nurse (RN), particularly newly qualified, is a persistent worldwide issue in healthcare, risking healthcare systems, patients’ wellbeing and their safety. (HWA, 2012) With regards to this investigation, we are considering here Djukic et al’s meaning of ECRN (Emergency Communication Registered Nurses) as “RNs who have practiced for less than 5 years” (Djukic et al., 2013). About 29,786 nurses have left their jobs since 2018 in the UK, which is 23.1 % greater than the number in 2013. (RCN, 2017). Furthermore, in many European countries including the UK, Ireland, Finland, Norway and Spain, the staff renewal rate for RNs leaving their jobs was from 5 to 17%. (Brook et al., 2019). It has been observed that the newly qualified nurses (NQN) presents a greater turnover rate, where turnover rate refers to the o the percentage of employees leaving an organization within a fixed time period, for instance a year. (Van Camp and Chappy, 2017).
Many studies have been performed to investigate the reasons behind resignations of NQNs and it has been noted that psychological factors including anxiety and stress due to work pressure in the early days of work right after graduation is the most common reason. (Tapping, Muir and Marks-Maran, 2013). It also leads the nurses to feel ill-prepared for their jobs, and hence they decide to quit their profession. (Eckerson, 2018) Additionally, a lack of self-confidence may also impact their performance, especially multitasking, and can lead to increased stress levels. (Morrow, 2009). These are few of the many factors that contribute towards an increasing turnover rate of NQN resulting in a problematic health care system. (Olson-Sitki, Wendler and Forbes, 2012) (Health Education England, 2014)
RETENTION OF NEWLY QUALIFIED NURSES: According to NHS reports published in July 2018, the number of registered nurses and health visitors has not increased significantly from 2017 to 2018. A small increase of less than 0.5% has been observed in the existing number of 282,661 Full Time Equivalent (FTE) over a period of one year, that is from 2017 to 2018, leaving 41,000 qualified nursing and midwifery posts vacant in the NHS in UK (Buchan et al., 2019). A recent report titled as “Tackling Nursing Shortage” published by the Open University argues that NHS spends more than £1.46 billion on recruiting temporary staff due to shortage of nurses, the same amount that can be spent on 66,000 qualified RNs. It has also been stated in the report that in 2017 NHS had to pay the working RNs for an overtime of 79 million hours at a premium rate which is 61% higher than the pay rate of a newly qualified nurse working full-time, due to the shortage of staff. If this shortage of nursing staff is overcome and the existing nurses are retained permanently in the hospitals, NHS will be able to save almost £560 million annually. (The Open University, 2018)
Additionally, the costs of training a registered nurse in the UK is estimated to be £70,000 which goes in vein once a nurse decides to leave his/her job. (Li and Jones, 2013). It is a critical moment for the NHS to address the high rate of nurse turnover and retention of nurses in the hospital particularly with an even increasing population of elderly patients. (Buchan et al., 2019) Currently, the NHS is facing a shortage of 40,000 nurses in England (RCN, 2019), which leads to a poor health provision in hospitals as the number of patients attended by a nurse increases, resulting in greater workload. (Finlayson et al., 2002)
This essay will entail a literature review associated with SIP (Service Improvement Proposals) (Manchester et al., 2014), which is determined to enhance the promotion of health care practices regarding retention of newly qualified nurses in the NHS, hence ensuring patient safety, better experiences of patients, staff members and health care administrators. (Nursing and Midwifery Council, 2015) (DoH, 2015).
Literature Review
It has been found that there is an increasing number of nurses quitting the Nursing and Midwifery Council (NMC) register: Between the years 2012 and 2013 almost 6.5% of working nurses left the NHS out of which only 1.2% left as they got retired and 1.5% left as per their wish (Nursing and Midwifery Council, 2018). There is still a gap as the data about rest of the numbers is not determined. It is estimated that the real number of nurses leaving is could be greater than 6.5% as a number of them quit work while they are still registered as well as some of them shift jobs within the NHS away from direct clinical care (Health Education England, 2014)(RCN, 2017).
There are two main themes to be followed to understand the retention of NQNs in NHS. Firstly, the reasons why the nurses choose to leave clinical settings. Many studies have been performed to investigate the reasons behind nursing students and newly graduate nursing staff leaving their jobs. The Health Foundation in collaboration with Nursing Standard quantitatively examined the attrition rates of student nurses using the legislation of Freedom of Information in 2018. They collected data from 54 universities that offered nursing courses. It was observed that a huge number of students suspended their degrees or left the programs early. Out of a total of 16,544 enrolled in these universities who are supposed to complete their degrees by 2017, 4,027 students chose to leave the program before graduating resulting in a 24% rate of attrition all over UK. In a stream of similar previous studies, more or less, same results were obtained which clearly exhibits a pattern. The mean rate of attrition in 2008 was recorded to be 25%, in 2010 it was found to be 28% and in 2017 it was reported to be 25%.(Buchan et al., 2019). The survey did not explicitly state the exact rate of attrition of individual universities, however provided a range from as low as 5% to as high as 50%. Hence, it is difficult to fathom the number of students quitting in each individual university, subsequently the reasons may also vary greatly due to different features of each institute. (NHS England, 2018)
The above survey studies are also supported in Jones-Berry’s qualitative study investigating the causes of quitting studies as well as newly qualified nurses’ turnover in the hospitals. Berry’s qualitative analysis appreciates the Health Education England efforts of examining the reasons behind above-mentioned issue and the publishing the “Reducing Pre-registration Attrition and Improving Retention (RePAIR)” report. This report states the major reasons behind nursing students and newly qualified nurses quitting their studies and jobs, respectively. It states that the nursing students mostly quit in their last years of degrees and first years of job due to problems they face during clinical placements including financial and academic pressures. Berry suggests that in such circumstances it would be highly effective for academic institutions to works side by side with health care facilities, clinics, hospitals etc. in order to create better placement opportunities for newly qualified nurses. (Jones-Berry, 2018).
Kenny et al. explores in a quantitative study the levels of satisfaction with respect to different job aspects such as work environment and becoming a part of a new graduate transition program that could impact a nurse’s decision to leave. 204 registered nurses in their first job after graduating from BN program were a part of a survey (Milton-Wildey et al., 2014) where the satisfaction levels of nursing education were determined. They measured the job satisfaction levels using a previously published research. Kenny et al. utilized structural equation modelling to deduce analysis. The theme of the study was perceived knowledge, confidence and preparation for transition from student to a real-life nurse. They found that the major indicator of job satisfaction was adequate preparation for work. They also found a strong relationship between intentions to quit work and the job environment including staff, support, quality of care, physical environment, professional development, and responsibility (Kenny, Reeve and Hall, 2016). The findings of Kenny et al., are largely reflected in the work of other authors including Karlsson et al., where they discuss the satisfaction of newly qualified nurses with their work and its association with smooth transition from academics to practical work life (Karlsson et al., 2019). Further, these findings are also supported in a cross-sectional study of Kaihlanen et al., regarding the the relationship between the components of final clinical practicum, the transition experience of newly qualified nurses and the intentions of quitting their jobs (Kaihlanen et al., 2019).
In another qualitative study performed using an exploratory design by Boulton and Beer, a web-based questionnaire consisting of open‐ended and fixed‐choice queries was completed by 121 clinical research nurses. They formed seven focus groups holding up sub-groups of 26 participants. The data collected was processed using inductive thematic analysis (Maguire and Delahunt, 2017). The greater number of nurses showed interest in proceeding their role at a research post for the following 5 years, while others showed intentions of identifying a role in the administration sector, clinical sector or simply retire. A very few numbers of nurses showed an interest in developing their careers as independent researchers (Boulton and Beer, 2018). This study helped the authors in determining the prompting reasons behind nurses’ intentions of quitting their jobs or the factors that attract nurses to retain their jobs. It was found that most of the nurses were enticed by the challenges and changes that they experience every day during their routine work as it provided a sense of “job enrichment” (Duffield et al., 2014). Secondly, nurses were also attracted to the family supportive working hours as they help them to manage the jarring demands of workplace and home (Powell and Greenhaus, 2010). Some nurses commented that a few characteristics of their job enables them to achieve a wide array of personal objectives by experiencing work in particular clinical areas as well as helps the in gaining elevation in clinical practices (Duffield and Franks, 2002).
Boulton also recognized the components that serve as a factor convincing nurses to quit their jobs. These factors majorly include a desire for further change, (Fawcett and McCulloch, 2014) concerns about loss of clinical aptitudes, rebalancing family/work obligations, short‐term contracts (Powell and Greenhaus, 2010), unsupportive businesses and constrained careers progress (Havaei, MacPhee and Susan Dahinten, 2016).
The study also focuses on the retention of both experienced research nurses and newly qualified nurses as it states that the hospital and other health facility employing organizations must cater the practices and policies that govern the workplace environment. These policies might inflict insecurities, diminish nurses’ aims and ambitions or debase their progress effecting their development professionally and career-wise (Duffield et al., 2014). It is also signified that nurturing the relationships of research nurses within and across several research sites and fostering newly qualified nurses’ inter- and intra-hospital network including teaching hospitals, may serve as a great mediator to approach a broader array of research and work-oriented goals. It may also help is developing a greater prospective for developing in their careers (Hall et al., 2004). Few nursing organizations including the Royal College of Nursing have played a major role to support the concept of “the professional recognition and status that researchers in other settings are afforded” (Price, 2009). This has led to convert the policies into practical research and clinical interventions successfully, and consequently augmenting the development of nurses’ careers into ‘Clinical Nurse Specialist’, ‘Advanced Practitioners’ and ‘Nurse Consultants’ (Rickard and Roberts, 2008).
Robson and Robson (2015) replicated a private sector Australian study to investigate the continuation of work by nurses in the UK National Health Service. They have explored the combination of factors and variables to understand the key issues that influence retention of nurses in an area where the employee attrition is a major challenge, further worsened by a maturing workforce. This study is a quantitative study based on a questionnaire survey (Cc, 2017), completed by the nurses themselves in the year 2010. For this purpose, nurses working in two UK National Health Service Foundation Trusts were questioned and assessed using seven design questions related to work and various demographics including age generation. Through correlation, multiple regression and stepwise regression analysis, the potential combined effect of various explanatory variables on continuation intention was assessed, across the entire nursing cohort and in three age-generation groups. Three variables act in combination to explain continuation intention: work-family conflict, work attachment and importance of work to the individual. This combination of significant explanatory variables was consistent across the three generations of nursing employee. Work attachment was identified as the strongest marginal predictor of continuation intention (Swenty et al., 2011).
Brook et. al. performed a qualitative analysis on the effective features of successful interventions to reduce turnover and enhance retention in early career nurses and concluding the research in the form of a systemic review (Seers, 2015). In this study, they evaluated the effective interventions by conducting review as per guidelines of “Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)” guidelines (Moher et al., 2009). The studies gathered were then examined qualitatively by utilizing the “Joanna Briggs Institute Critical Appraisal” tools for “Quasi Experimental and Randomized Controlled Trials”(Joanna Briggs Institute, 2018). It was observed that the most effectively promising solutions for enhancing nurse retention is provision of internships and residency programs. It also showed that the nursing staff who received transition training or orientation after graduation in the first year of job for a time period of at least 27 weeks had lesser intentions of quitting their jobs. These transition training sessions were mostly mentored by teachers and preceptors (Brook et al., 2019). This study has also been supported by Karlsson et al., and Hussain et al., in 2019 separately, where they identify the satisfaction levels of newly qualified registered nurses in the first years of their jobs and their intentions of continuing the work (Karlsson et al., 2019) (Hussain et al., 2019).
Many interventions for retentions of nurses, particularly newly qualified nurses have been investigated to effectively solve the issue of nurse turnover in the health-care facilities. Cowden and colleagues (2011) have examined the networking between leadership policies and practices of managers in hospital and intentions of nurses to retain their current jobs. The study indicates a direct relationships between innovative leadership practices, a healthy and supportive work environment and nurses’ intentions to stay at the same place. (Cowden, Cummings and Profetto-Mcgrath, 2011). A similar conclusion was drawn in a study performed by Lartey and colleagues (2014) where they have explored the effectiveness of applying multiple interventions for the retentions of RNs and NQNs in the hospitals. They have suggested that the nurses and managers in leadership roles must be informed of the ways that can create better opportunities for retention of nurses and establish quality care in the facilities (Lartey, Cummings and Profetto-Mcgrath, 2014). In a qualitative study performed by Park (2010) presented in the form of an integrative review, the impacts of orientation and training programs as an effective intervention for the retention of newly qualified nurses have been explored. It has been found that these training sessions help fresh graduate nurses to gain more confidence, competency and intentions of job retention (Park and Jones, 2010). The same idea has been ideally supported and appreciated by Brook et al., (2019), Kaihlanen et al., (2019) and Karlsson et. al. where they emphasized on the idea of smooth transition of graduating nurses into practical work environment as Registered Nurses. (Brook et al., 2019) (Kaihlanen et al., 2019) (Karlsson et al., 2019).
The work environment play a great role in the development of positive intentions for retaining one’s job when compared with employer-directed interventions such as leader-member exchange, teamwork and autonomy (Cowden, Cummings and Profetto-Mcgrath, 2011) (Rickard and Roberts, 2008). The nurses all over UK exhibit a homogeneous behavior across the three age-generations regarding the reasons behind intentions for continuation or discontinuation of job (Robson and Robson, 2015). A few studies have clearly stated the use of multiple interventions at the same time to improve retention of nursing staff in the hospitals (Salt, Cummings and Profetto-Mcgrath, 2008)(Lartey, Cummings and Profetto-Mcgrath, 2014) whereas a few studies emphasize on introducing one effective intervention at a time to retain nursing staff at their jobs. (Cowden, Cummings and Profetto-Mcgrath, 2011)(Park and Jones, 2010).
Change Management
It is a challenging task to implement change to a setting that is already working according to a certain strategy. Introducing a change to such an acute setting can result in stressful barriers including conscious or unconscious fear and resistance towards new implementation by the staff or residents subsequently arousing a lack of cooperation. Management of change implementation requires a careful strategy and recognition of different kinds of barriers that may prove to be crucial for application of change to be successful. It also requires identifying each individual’s nature and their differences, including staff and residents in our case, as well as recognizing variable mindsets and stresses of all the staff members. (Hussain et al., 2018). A few credible studies have shown that the “Lewins (1947) Change Model” emphasizes on alterations in behaviors of people involved in the change management, consequently Lewin’s Change Model or Theory (1947) is idealized in this situation to be the best fit to carry out execution of my service improvement plan (Mulder, 2012).
Lewin’s Change Model was formulated by Kurt Lewin in the 1950’s as he identified change as a continuous progress and indicated that a change can be successful only if it is accompanied by appropriate pushing and the restrictive forces that led to the change at the first place. Lewin states that the driving force is responsible to lead an organization on a path of completely transformed state whereas the restraining or restrictive forces offer resistance factors including social barriers that hurdle the change and can result in difficulties in the development of change. As acknowledged by the law of physics as well, Lewin believes that a stable change implementation can occur only when both the driving and restraining forces are offered in equilibrium (Burnes, 2004).
RETENTION OF NEWLY QUALIFIED NURSES: Kurt Lewin has designed his theory in the form of three linear stages to address the change implementation. This theory is broadly known as the ‘fundamental approach’ for change management. The three stages are classified as unfreeze, change and refreeze. As per the field model of Lewin, if an organization wishes to implement change effectively it needs to ‘unfreeze’ the current state so that it can switch into a state of ‘change’, for the change to settle in and afterwards circumstances have to “refreeze” so that the implementation of change permanently establishes and is efficiently adopted (Hayes, 2018).
Kotter’s 8-step change model (Kotter, 1996) was presented by John Kotter, a business professor at Harvard Business School in 1995 in his book “Leading Change”. The model is based upon the three-staged model of Kurt Lewin and equally emphasizes on all eight steps in order to execute a successful change implementation. The eight steps of Kotter’s change implication include developing urgent situations for bringing change, formulating a powerful alliance, for instance stake holders, partners etc., visualize the consequences that will be brought by the change, communicating the aim and vision of change, fighting the barriers, creating smaller and short-term goals, growing on the change and lastly permanently embedding the change in the setting.
RETENTION OF NEWLY QUALIFIED NURSES: The three-staged Lewin’s change model (Burnes, 2004) and Kotter’s eight step change theory can be effectively used side by side in a service improvement plan as Kotter’s model is based upon the three stages of Lewin’s model. I will basically combine the stages and steps of both models according to my requirements and at some events will even modify the sequence of steps to fit my demands in the frame.
After completing the literature review, I identify the urgency of situation that needs to be addressed at the earliest. As we have already established that a high rate of nurses turnover in the health care facilities results poor quality of health management, risks patient safety, increases cost for NHS, leaves nursing positions vacant and put more work pressure on existing nurses, the issue of retention needs to be addressed immediately as per Kotter’s 1st step (McGrath & Bates, 2013). Following the identification of urgency, it is required to conduct a baseline audit to examine a cross-sectional observational study in order to gather the gist of circumstances (Setia, 2016). This examination will include the estimation of turnover rate of newly qualified nurses in the past year that is the number of nursing staff members that quit their jobs in previous year as well as the number of nursing staff that has exhibited intentions of leaving their jobs. This data will later help me to keep a firm record of the improvement in service and a comparison of situations before and after the implication of my service improvement plan.
At this step, Kotter’s change model (McGrath and Bates, 2013) urges us to communicate the basis of change in a dramatic manner in order to establish emergency situation for change implementation (Appelbaum et al., 2012). This can sometimes result in chaos and distortion in the flow of work in acute settings as well as it can lead to development of stress and panic among the staff. It can also result in a lack of interest of the staff members in the implementation plan (Northouse, 2016). According to my opinion, a good leader always considers the well-being of people working under him, therefore I will refrain from using this mode of leadership and introduce the idea of change in slow yet extremely effective manner. (Kitsos, 2016)
Although, Kotter’s change model exhibits a linear plan following strategy, I have modified it as per my requirements. Thus, I am following step three before step two, that is visualizing our outcomes of change. Therefore, at this stage, I have already visualized the outcomes and goals of my improvement plan that we need to establish a higher retention rate of nurses and reduce the turnover rate in our healthcare facility. (Appelbaum et al., 2012). My vision is a consequence of my dissatisfaction with current system of administrating leadership policies that aid in retention of NQNs and almost no transition training for newly graduating nurses when they join the workforce. Hence, this demands a need for change implementation. (SONENSHEIN, 2010).
My service improvement plan involves one major intervention: offering transition training and orientation sessions to newly graduated nurses in order to help them prepare for the new phase of their lives, which will directly impact the retention of NQNs. (Park and Jones, 2010) (Cowden, Cummings and Profetto-Mcgrath, 2011). In the next step, I will use the second step of Kotter’s change model (Kitsos, 2016) and the first stage of Lewin’s change model, that is unfreeze (Mulder, 2012)(Hussain et al., 2018) in combination with each other to introduce my ideas and formulate a team or stakeholders for the purpose of communicating my ideas of interventions for retention of newly qualified nurses to a guiding team (MindTools, 2017). My team will consist of a group of people classified as “early change adopters”, that will include focal persons for recruitment, practical development of change and representatives for financing and funding. (Hewitt-Taylor, 2013).
My ideas of change will prove to be cost-effective for NHS and will decrease the amount spent each year to address the issue of the high turnover rate of nursing staff (RCN, 2017) (Buchan et al., 2019). I plan to play a role with complete transparency as an agent of change and while communicating the circumstances that led to the need for change……………………………………………………………………….continued
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