Strategies for Staff Shortages in the NHS

Strategies for Staff Shortages in the NHS Chapter 1 Introduction 1.1 Background: British National Health Service (NHS) has experienced a sensitive shortage of qualified nurses. This has placed retention issues on the political agenda. Nursing shortage is one of the greatest problems for the hospitals in the UK. Hospitals are placing greater importance on retaining their current registered skilled staff. It’s a difficult process and to do this they required to have deep knowledge of the needs and wants of the nursing staff .Management have to know what motivates nurses to stay. From that point of view, many hospitals carry out retention or exit surveys to understand the causes of leaving. According to Seccombe and Smith (1997), from 1987 to1995, within nine years nurse training fell gradually from 19,600 to 14,200 per year. An study (Lader 1995) of the 1991 Census proved that only 68% from them with nursing qualifications in U.K were actually working in nursing profession. Also the research found that 16% of the remaining were working in another profession and 15% out of paid work. Vacancy rate in NHS is very high now. Because of poor recruitment and retention system NHS have been forced to operate with vacancy rates for registered nurses up to 20% which was national vacancy rate of around six thousand six hundred in 1996(Review body for Nursing Staff 1997, cited by Maylor et al. 2000). Suggett (2003) reported that Wandsworth Primary Trust care has 15% vacancy rate for the nursing post at present and same vacancy rate exist for Health Care Assistants. Lowest vacancy rate(8%) exist for Allied Health Professionals. Nursing have the highest vacancy rate (35.9%) of the current labor force within the Trust. Gray and Phillips(1996) said currently NHS facing turnover and it stands at around 14% per annum for registered nurses (RGNs). Supported by (Seccombe and Smith,1997), he also added that it was far higher for nurses who have finished their training in recent times. Research found on turnover which supports these statistics, with around 40% of nurses had a great intention to leave nursing job from NHS within the next three years (Beishon et al., 1995). The reality is that turnover is maximum for nurses under 35 years of age. Hence it is an important economic problem, considering the standard cost of  £50,000 that taxpayers pay to train a RGN(Audit Commission, 1997). Suggett(2003) said from April 2002 to March 2003, statistics report showed that nursing post has turnover rate of 16.3%. Also Allied Health Professionals had 25.2% and Health Care Support Workers had 11% turnover rate. He also said that it was a big issue for the Trust because huge proportions of recruits left the job within two years after appointment. After first two years of employment 22 Allied Health Professionals and 23 Nurses left. Actually from this report it can be found that Nurses are not satisfied with their job and they are leaving early stage of their joining. As a result it creates serious problem for NHS. According to Maben (2008), London has the highest vacancy and turnover rate in the UK, with a dependence on agency and international staff. For example, vacancy rates in London were reported to be twice as high as the NHS average for some occupations, within 2016 the population of the London is projected to grow by 700,000, and well-trained, skilled and motivated nurses are very essential to meet shortage of the city. The Jonas Centre For Nursing Excellence (2006, p.9) reported that substantial attention has been given on improving nurses working environments as a principal approach for improving retention. The Magnet Recognition Program developed by the American Nurses Credentialing Center (ANCC) based on The 1983 Magnet Hospital Study’s findings, have largely supplied the criteria by which such supportive environments are defined and evaluated. According to Kramer and Schmalenberg (2005), the original Magnet study commissioned by the American Academy of Nursing, observed the characteristics of hospitals that enjoyed reputations as good places to work and which, even though a large-scale nursing staff shortage at that time, were successful in retaining nursing staff. One of the Magnet program objectives is recognize nursing services that use the Scope and Standards for Nurse Administrators to build programs of nursing excellence for the delivery of nursing care to patients Nurses across the nation are reporting that stress and dissatisfaction increased significantly with nursing (Boyle et al. 1999). Nurse-physician conflicts add to an already stressful work environment (Rosenstein 2002). One in five nurses plan to leave the profession within the next 5 years (Letvak 2002). Considering all these issues, it becomes vital to search for ways to retain experienced nurses. Researchers are trying hardly to solve the retention problem of NHS. One research (Newman and Maylor, 2000) found on retaining nurses in London region. This study identified the factors of nurse satisfaction and recommended a retention strategy. They recommended improving pay policies, management techniques, training facilities, career progression opportunities, service quality and patient satisfaction 1.2 Why is this area important within the NHS: Audit Commission (1997) reported that High staff turnover and recruitment is a problem for NHS trusts. It causes critical posts to stay vacant for long periods of time with direct consequences for patient care. They explained that Replacing staff can be an expensive business, costing trusts up to  £5,000 for each position filled. There is an also hidden cost of taking on new staff; who may take a year to learn to do the job efficiently and need extra training. Trust managers need to understand why staffs leave, shape the staff attitudes that influence job loyalty, and implement practical measures such as improving opportunities for training, so staffs dont have to leave to increase their skilled. Local and national economic factors may be out of the control of the NHS. The National Health Service is the largest employer in Europe and it has 142,000 staff in London alone .United Kingdom did not have enough doctors and nurses to meet demand. Though, there are staff retention challenges in all the NHS, but the major problems were mainly heard in some busy cites, particularly London(Maben 2008) Finlayson et al.(2002) said that government always feels the pressure of NHS nurse turnover problem. The problem is gradually rising. Government declared to recruit additional 20000 nurses in NHS hospitals within 2004. The demand were to be fulfilled by bringing back nurses who left the NHS, recruiting skilled nurses from abroad and increasing the quality training plan for nurses. Government recruited 6000 and 5797 nurses respectively in 1999 and 2000. In 2001, 713 nurses were recruited. According to The Royal College of Nursing(2000), at present 22000 nursing job are vacant which is whole time  equivalents. The college also reported that NHS will require to recruit more than 100000 nurses by the end of 2004 if retirement levels and other losses remain unchanged. Through training less than half of the demand will be met. From the above report it can be seen that retention is a very big issue for NHS. NHS skilled staffs are leaving their job. Nurses are doing the great job for the society. Those who qualify in Nursing have already demonstrated their intelligence, application and dedication to the sick by undergoing a usually arduous professional training. So, it is our duty to keep the skilled nurses in their profession for the benefit of society by proper retention policy. NHS is concern about how to overcome this problem. Researchers are trying to solve this problem in different ways. Recruiting new people is more costly than retention. Moreover they are not trained and it also time consuming to train them. So it is better to try retain the skilled nurses to reduce the pressure. Considering this situation writer of this report feels the importance of staff retention in NHS. 1.3 Rational: Nurses are the lifeblood of any hospital. The NHS in England employs qualified nurses always. From last 10 years, recruitment and retention of nursing staff has taken on crucial importance; therefore any study that demonstrates that the working environment has an impact on nurses’ recruitment, retention and performance is of importance to the further success of the NHS. NHS facing challenges to retaining nurses at both national and local level. According to Sugget(2003), The local NHS Plan had an aim for Wandsworth primary care trust include 40 nurses and 18 Allied Health Professionals within 2005.The South West London Workforce Confederation recommended that to accomplish these figures Trusts need to attract and support newly qualified nurses and return to practice clinical employees. This means that NHS is trying hard to keep their skilled nurses. Purpose of this research is not only introducing a standardised pay structure but also have a target to improve retention and staff morale. Employees will be identified as facing recruitment and retention problems like works officers or qualified manager. The object of this research is to examine current retention problems for facilities staff experienced by NHS Trusts.  The key purpose of this research is to find out the best Nurse retention strategy for NHS that can be helpful for the other researcher to carry out their future research. As I made my mind to build my carrier as a HR manager, I have chosen research area on staff retention. Staff retention will give me vast experience on HR management. In retention strategy there is a vast scope to gain some practical managerial knowledge and experience relation between manager and staff. Observing the NHS staff problem, I have chosen NHS to carry out my research on staff retention. 1.4 Aims and Objectives: Aim: Aim of this research is to identify good practice in order to make recommendations on how the NHS could retain their nursing staff with a range of skill and experience. It is known that any organisation will have more success in the HRM task if it is committed to valuing its employees by promoting their professional and personal development Research Objectives Review the existing literature on nurse retention Examine the factors that affect retention like pay policies, reward, working flexibility, work-life balance, workload etc. Identify the key retention factors Key theories to be Use: This research will focus on existing HRM model and Retention strategy to achieve the aims and objectives. The conception of new retention strategies will be a major spotlight for nursing administration as a lack of nurses recurs and turnover of staff becomes a strong problem. 1.5 Chapter Outline: Chapter Two provides a critical review of the literature on retain skilled staff working within NHS employment in order to create the context for the research. Key points of this chapter are nurse satisfaction, cause of leaving and retention strategies Chapter Three explains the research methodology, provides information on research process, strategy, data collection, data analysis (qualitative and quantitative) and ethical dilemmas encountered. Chapter Four begins with an data analysis on the research questionnaires. Both qualitative and quantitative analysis was presented. Also analysis findings were presented here. Chapter Five re-evaluates the findings by referring back to the research objectives. It then provides a short review of the research including recommendations for both NHS. It provides an evaluation of the study and suggests areas for further research. It also includes some limitations and shock of the researcher. Chapter-2 Literature Review 1.Introduction: Employee turnover is known as a most important organizational/business phenomenon. Employee turnover is very crucial to organizations, individuals, and society. Employee turnover can cause a considerable cost in terms of socialization, recruiting, training, and disruption. From the company’s point of view turnover also represent the range of indirect cost. Given the impact of turnover, it is vital for the manager and future manager to be able to analyze, recognize, and successfully deal with employee turnover (Mobely 1982). Here he tried to focus on the importance of employee turnover control for an effective management in case of saving cost. (Dell and Hickey 2002) added that turnover has huge economic impact on the organization, both in direct and indirect costs. Translating turnover into numbers that executives understand is essential because they need to appreciate the true costs. Managing retention effectively is a continuous challenge for any business organization. The retention issue had been highly focused since the last decade, and, from all indications, the problem will increase more in future decades. Most HR executives find retaining talent to be big problem even in slow economic times (Phillips and Connell 2003). In a survey during the 2001-2003 recession, ninety percent of 109 executives reported that they were finding it difficult to attract and retain the best people in the organization (Dell and Hickey 2002). Newman and Maylor (2000) reported that National registered Nurse has declined by more than 14,000 leaving the NHS with the worst nursing shortage in 25 years with a record 8-17000 shortfall of qualified nurses. Buchan(2000) said that from 1990 to 1998, the number of qualified nurses decreased by 8000 . This chapter is designed to focus on the existing literature on nursing retention. At first some definition is given. Then cause of nurses’ leaving is focused. Finally some retention strategies are discussed. 2. Definition: An understanding of basic distinctions between retention and turnover is very important. Phillips and Connell (2003, p 2) defined the retention and turnover in following ways: 2.1 Retention: is the percentage of employees remaining in the organization. High levels of retention are desired in most job groups. 2.2 Turnover: On the other hand turnover is opposite to the retention, refers to the percentage of employees leaving the organization for whatever reason(s). 2.3 Turnover rate: refers to the rate of individuals leaving. 2.4 Tenure: is the length of time an individual is employed by the organization and usually related to the concept of the employee loyalty. A loyal employee usually remains with an organization for a long period. In many organizations it is desirable to have long tenured employees, although this situation taken to extreme can also create problem. 3. Retention As a Critical Issue: Retention is a strong critical issue for any organisation. The theory of employer-of-choice has intensified in the last decade. Employees always want to work for best employers. Phillips and Connell (2003, p3) said organisations struggle to be the â€Å"the best company work for†. The statement â€Å"the best company work for† translates into lower rates of turnover. Levering and Moskowitz (1993) supported stating that many companies attempt to build the type of organization that can at least meet the preferred standards. Becoming an employer -of -choice often involves the issue of acquiring the best talent for the organization, motivating employees to improve performance, Keeping them satisfied and loyal, developing employees so they can grow and contribute skills, and ultimately retaining those employees( Fitz-enz 2000) 4. Cause of leaving : 4.1 Social Environment: The social environment of the workplace is the initiator of a nurses plan to stay or leave. Moreover social environment is a determinant of work disappointment (a depressing influence), and work excitement (an encouraging influence). Moos(1994) said that these factors directly influence workplace stress, leading to job satisfaction or dissatisfaction . According to Bratt et al.(2000), Job satisfaction or dissatisfaction is the powerful forecaster of intent to stay or leave the job. 4.2 Burnout: Burnout can cause job dissatisfaction. Garret and McDaniel(2001) said that enviro- nmental uncertainty are very important in all features of burnout. Aiken et al. (2002) reported that nurses with the lowest nurse-to-patient ratio experience less burnout and dissatisfaction than those with highest ratios. The researchers claim that 43% of nurses who said strong levels of burnout and disappointment intended to quit their jobs within a year. Only few nurses did not complain of dissatisfaction. When nurses work rotating shifts, there is a significant decrease in job satisfaction (Bratt et al. 2000).Newer nurses experiencing more job stress as compared to experienced nurses. 4.3 Autonomy: Nurses always desire increased autonomy working environment. (Nevidjon and Erickson 2001).Aiken et al.(2002) claim that autonomy is one of the factors which has decreased emotional exhaustion of nurses in American magnet hospitals. In another research on this hospital showed that autonomy had influenced the managerial trust, their appraisal of the quality of patients care and also job satisfaction (Laschinger and Thomson 2001). Davidson et al. (1997) established the value of autonomy by representing that decreased job satisfaction is connected with decreased autonomy. Bruffey(1997) said autonomy is ultimately influenced by the leadership of their managers. There is a positive connection between job satisfaction and nursing leadership. Management system, allow the nurses to do their jobs effectively, was related to job satisfaction( Bratt et al.,2000). Tumulty et al (1994) found that though autonomy had a significant impact on job stress, it was not a major determinant of stress as task orientation. Also Ingersoll et al. (2002) said that autonomy was a positive observation of task orientation related with increased job satisfaction and aim to stay. This idea is supported by Davidson et al. (1997) with the result of increased scheduling and decreased work load leading to decreased job stress. The researchers argued the advantages of better communication improving the awareness of nurses concerning autonomy burn out, work pressure and task orientation. Some researcher stressed the significance of management or leadership behaviours. Managers or leaders perceived as equitable decreased staff perceptions regarding work pressures and increased perceptions regarding autonomy(Taunton et al. 1997). Bruffey(1997) said these factors collectively led to lower job stress and its expected association with intent to quit. 4.4 Work Pressure: Bratt et al. (2000) identified the work pressure as the most familiar and important factor of organizational work satisfaction/dissatisfaction. McNeese-Smith(1999) identified several factors of work load which bring job stress for nurses. These were: (a) overload due to heavy patient assignment, too many patient needs, and/or too few staff members to meet these needs. (b) exhaustion; (c) fear of making a mistake due to exhaustion and (d) high patient acuity. Bratt et al. (2000) reported some additional work stress factors which influence the nurses to leave the job. These include rapid turnover of patients, shift work, lack of available equipment, managerial pressures, excessive noise and lack of space. According to Aiken et al.(2002), Nurses with increased patient loads in workplace were more likely to explain experience of burnout, job dissatisfaction and emotional exhaustion than their colleagues with less patient loads. So autonomy is a key factor to reduce work stress for work load. Because work load is a originator of nurse intention to leave 5.1 Job Satisfaction of Nurses: There is a lack of agreement on the meaning of nurse satisfaction (Hale 1986, cited by Maylor et al 2000).Two definitions stemming from the 1980 stand out. The first one highlights psychological factors according to Bush(1988), the perception that one’s job fulfils or permit the fulfilment of one’s significant job values, providing and to the extent that those values are congruent with one’s requirements. The second one highlights workplace factors like recognition of achievement, enough staffing, appreciation, autonomy, childcare facilities and quality patient care.(Butler and parsons,1989). Nurse satisfaction can be depends on effective patient care. Maylor et al.(2000) noted that it is very crucial to have ability to give good patient care. 5.2 Determinant of job satisfaction: Job satisfaction analysis is driven by attempts to concentrate on the issues of industrial action, leaving or turnover and personal joy at work. Researchers are interested in the bond between job satisfaction and efficiency and financial and non-financial reward. According to the influential work of Freeman (1978), job satisfaction can be separated into those considering labour force as a whole, those analysing qualified groups such as lawyers, nurses and academics, those which inspect the impact of individual characteristics like age, sex, race/education and those which explore the outcome of job-related features such as trade union membership, self employment and establishment size. Some important determinants of work place satisfaction have been recognized which may be supportive in the thought of job satisfaction in nursing. Diversity of individual characteristics have been identified to have special effects on reports of job satisfaction. That diversity includes gender, race, age, marital status, children and education. The major effects are usually connected with gender and age. According to British Household Panel Survey (Clark and Oswald 1996), Females are highly satisfied with their job in the UK. Earlier proof recommends that age has either a linear or U-shaped bond with job satisfaction (Clark et al. 1996). That means older workers usually being more satisfied with their current job. A set of studies have focused on the analysis of comparison effects on job satisfaction. Comparison effect means, staff may have several idea of relative or ‘comparison’ earnings which enters their utility function. So job satisfaction is not only influenced by a staff’s personal total earnings, but also by their earnings that is comparative to some comparison group/desired level. Clark and Oswald (1996) summarized that satisfaction or dissatisfaction can be created in workers mind because of individuals’ comparison of their present job with the other job. So, job satisfaction is not only affected by individual earnings but also by their earnings related to expected level. Both absolute and comparative incomes have positive influence on the job satisfaction of staff (Sloane and Williams 1996). Clark and Oswald (1996) gave some proof that expectations are influenced by staff’s age, educational background and profession. Determinant of job satisfaction can be found from the inconsistent job features of staff. Working hours, establishment size, union membership and profession have important effects on job satisfaction. In the case of nursing staff, it is very crucial to evaluate the impact of improved working environment on their job satisfaction. Clark (1997) discovers a important influence of ‘work values’ on job satisfaction. More exclusively, staffs that highlight the importance of payment are more likely dissatisfied with job whilst staffs that highlight job place relations are associated to support job satisfaction. Nurses are more likely dissatisfied with their job because they are normally considered as low-paid staff. 6. Nursing in Multi ethnic minority: The racial harassment of ethnic minority nurses continuous to be a regular feature of their working lives in the NHS. This racial harassment from patients could be broken down into two distinct forms. According to (Beishon et al. 1995) First, there was a form of harassment where racial motivation in the incidents was clear because of accompanying verbal insults or because the patients had made it clear they did not want to be ‘nursed’ by an ethnic minority nurse. Secondly there, there was a more subtle form racial harassment where white patients did not explicitly mention nurse’s ethnicity, but rather treated ethnic minority nurses in a relatively unfavourable way to their manners with white nurses. A black nurse reported how differently she was treated from her white colleagues (Alexander and Dewjee 1984). However the things have begun to change and NHS training authority has taken on training projects directed specifically at race issues (Beishon et al. 1995). 7. Retention Strategies: 7.1 Creating A Motivating Climate: Because the organization has such an impact on the factors that extrinsically motivate employees, it is important to examine organizational climates or attitudes that have direct influence on worker morale and motivation. Huston and Marquis(1989) said that frequently organizations overtly or covertly reinforce the image that each and every employee is expendable and that a great deal of individual recognition is in some way harmful to both the individual and the individual’s productivity within the organization . Just the opposite is true. Individuals who have a strong self-concept and perceive themselves to be winners are willing to take risks and increase their productivity to achieve their productivity. Peters and Waterman(1982) stress that organizations must be designed to make individual employees feel like winners. The focus must be on degrees of winning rather than on degrees of losing Another wrong attitude held by some organizations is at the opposite extreme. Korman et al (1981) supported that if a small reward results in desired behaviour, then a larger reward will result in even more of the desired behaviour. That means an employee’s motivation should increase proportionately with the amount of incentive or reward. Nurse managers should think excellence and achievable goals, and reward performance in a way that is valued by their staff. These are the cardinal elements for a successful motivation-reward system for the nursing organization (Kirsch,1988). To the contrary, more incentives or reward systems were actually less motivating, as they produce a felling of distrust or being bought. Increasing incentives may be perceived as a violation of individual norms or of guilt (Bowin,1987). Managers can also create a motivating climate by being positive and enthusiastic role models in the clinical setting. Studies by Jeskins and Henderson (1984) demonstrated that managers’ personal motivations are the most important factor affecting their staffs’ commitments to duties and morale. Positive outlooks, productivity and accomplishment are contagious. Radzik(1985) stated that employees frequently determine their job security and their employer’s satisfaction with their job performance by the expression they see on their manager’s face. That means unhappy managers frequently project their unhappiness on their subordinates and contribute greatly to low unit morale. 7.2 Managing Career Development in nursing: Some philosophies about responsibilities for career development have been reflected in nursing. Donner and Wheeler(2001) have argued that nurses do require to take greater responsibility for career planning and development. They should follow a framework discussed by King (2001) which includes identifying opportunities, developing and implementing a good career progress. Donner and Wheeler(2001) added that to deliver high quality of caring service all educators, employers and professional business organizations should work with nurses on their career development plans and activities . According to (UKCC 1999 ), in UK, for long period it has been known that continuing professional development (CPD) has an significant function in nurses’ individual career development and retention. It also enhances the quality of patient care. There was a debate for a long time that local health service employers must recognize and understand the value of appropriately controlled CPD programmes in attracting, motivating and retaining high quality staff (DH 1998). Strategy for CPD for nurses were set out in Making a Difference ( Robson and Banett 2007) in which it was debated that CPD should include not only attending courses but also learning at work through experience, critical incidents, audit and reflection, maintained by peer review ,mentorship and clinical supervision. It was a matter of great concern that practitioners and employers were puzzled by the creation of new courses and lack of apparent links to career paths and that a more determined structure was needed 7.3 Working Condition: From a human resource management viewpoint, it can be said that working conditions have an affect on staff morale. Good working conditions will contribute to improving retention staff (DH 1997). The different ways in which working environment can affect nurses and manipulate their decisions about direction and retention in the occupation have raised from a substantial body of study on job satisfaction and workplace stress. Reconsidering the previous history on stress among general nurses, McVicar (2003) expressed that the major sources of stress identified are leadership, work pressure, management style, coping with emotional or touching demands of care, and relationships between occupational groups. He also added shift working and lack of reward also emerging from more recent research. Deep study on job or workplace satisfaction in nursing profession has exposed that aspects of work which recognized in the stress literature also come into view as sources of satisfaction or dissatisfaction. Nolan et al (1999) said, staffing levels enough for nurses to feel confidence to offer better quality care if there are availability of supplies and equipment. And it also depends on the nature of work place relationships with colleagues and nursing managers. Positively it has long been acknowledged that both physically and mentally nursing is a challenging work (Davies 1995). Handling and lifting patients and ‘being on one’s feet’ every day is not very easy. It can cause not only work stress but also bodily injury like strained backs. The emotional element of nursing can be equally important and demanding, involving caring for patients when they are dealing with death and dying and loving for upset patients and relatives. Rise of these demanding emotional elements to overcome the challenge can be a source of satisfaction. On the other hand, low moral and work stress can be created when nurses feel under-supported and under resourced in working environment, particularly in relation to staffing. (Cameron and Masterson 2003). McVicar (2003) said study on stress has exposed the level to which a range of physiological and psychological symptoms have been linked with diverse sources of stress and that distress is very much correlated with absenteeism, ill-health and poor retention . Shields and Ward (2001) expressed that Job frustration has been reported as the distinct most vital cause of intention to leave among NHS nurses. In US, it was suggested that when staffing levels are decreasing there is low levels of job satisfaction which causes poor effects on work stress and quality of patient care (Aiken et al 2002). He also added it also affect the retention of nurses in clinical practice. According to Coomber and Barriball (2007), a current review of the international literature illustrates that stress caused for workload, workload scheduling and leadership issues influence disappointment and retention for nurses. From policy development, a range of strategies have been identified and impl