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Table Of Contents
Appendix 1: Summary of Literature Review Strategy 22
Appendix 2: Application of CASP Framework 23
Introduction and Background
Retention of a 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) present a greater turnover rate, where turnover rate refers to the o the percentage of employees leaving an organization within a fixed 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 a 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)
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 one year, that is from 2017 to 2018, leaving 41,000 qualified nursing and midwifery posts vacant in the NHS in the UK (Buchan et al., 2019). A recent report titled “Tackling Nursing Shortage” published by the Open University argues that NHS spends more than £1.46 billion on recruiting temporary staff due to a 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 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 vain 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 ever-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 a 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 the rest of the numbers is not determined. It is estimated that the real number of nurses leaving it could be greater than 6.5% as a number of them quite 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 nurses choose to leave clinical settings. Many studies have been performed to investigate the reasons behind nursing students and new 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 the UK. In a stream of similar previous studies, more or less, the same results were obtained which 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 university, subsequently, the reasons may also vary greatly due to the 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 the above-mentioned issue and publishing the “Reducing Pre-registration Attrition and Improving Retention (RePAIR)” report. This report states the major reasons for 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 a 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. to create better placement opportunities for newly qualified nurses. (Jones-Berry, 2018).
Kenny et al. performed a qualitative study to understand the levels of satisfaction concerning different job aspects such as the 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 the 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 previously published research. Kenny et al. utilized structural equation modeling to deduce analysis where 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 a 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 relationship between the components of the 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. 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 the workplace and home (Powell and Greenhaus, 2010). Some nurses commented that a few characteristics of their job enable them to achieve a wide array of personal objectives by experiencing work in particular clinical areas as well as helps them 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 facilities employing organizations must cater to the practices and policies that govern the workplace environment. These policies might inflict insecurities, diminish nurses’ aims and ambitions, or debase their progress affecting 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 networks 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 converting 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 the 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 the nursing employee. Work attachment was identified as the strongest marginal predictor of continuation intention (Swenty et al., 2011).
Brook et. al. performed a systemic review using qualitative methods, a method performed by Seers (2015) as well (Seers, 2015) on the effective features of successful interventions to reduce turnover and enhance retention in early career nurses. In this study, they evaluated the effective interventions by conducting a review as per the 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 are the 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 the job for 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)………………………………………………………………..continued
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