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Strategies for Staff Shortages in the NHS

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Chapter 1


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 don't 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 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.


Literature Review


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 “the best company work for”. The statement “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 nurse's 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 implemented to improve working environment. In recent times those strategies have been brought together and developed as one key component from four included in ‘Human Resources in the NHS Plan’ (DH 2005). To getting better quality of patient care, effective strategies should be considered to increase the numbers of staff in a post. These are determined by the recognition that levels perceived as insufficient for workloads are harmful to morale and may create worse problems of retention.

7.3.1 Social and Recreational programs:

Another positive working state that has gained popularity in recent years is the condition of social and fun programs in favour of employees. Huston and Marquis (1989) said that community programs might be include functions like as teas, dinners, and receptions to nobility employee activities and longevity of service. Other social events could include yearly Christmas party and summer barbecue or picnics. Those programs allow the employees and their families to appearance social relationships both inside and outside the organisational environment. In years of 1970s more than 50,000 American companies had developed some form of recreation program for their workers (Famularo 1986).

These programs are commonly used to link employee relationship and success needs which are generate a sense of belonging, improving self-confidence, and growing employer faithfulness. Employees find it easier to recognize with a corporation that cares in relation to their off-the job human requirements and the meaningful relationships with link employees who work jointly cooperatively both inside and outside the organization (Huston and Marquis 1989, p 373).

In many businesses, the recreation that is formal into a strength program either on or off site. Although traditionally reserved for organization only in corporate America, fitness programs are now essential for all employees. This system has been developed in Japan also. Fit, happy employees create more, are less likely to be lacking, and are fewer possible to be wounded (Bergstrom 1988).

To develop a recreational program, the originations have to follow a number of principles. Huston and Marquis (1989) said first, the program should provide the greatest chance for the maximum amount of sharing by greater the number of employees. Second, the recreation should be more than “play”; it is thankful to include a wide variety of performance to accommodate the broad range of interests in a group of individuals. Last one, the program has to be flexible so that it can cultivate and modify as new requirements and activities occur. But (Glueck 1978) report that study of the preferences of employees indicated that leisure services are the least preferred of all advantage and services offered by the organizations.

7.3.2 Job Security:

Job security is an elementary human require that in support of many people and that is more important than both salary and progression. Organizations that are loyal to job safekeeping “make every stab to afford continuous employ or income for at least some activities or program to support this commitment. (Luxenberg 1983, cited by Huston and Marquis 1989) .Quite a few of these forces motivates employees toward unionism, grave clash in superior-subordinate relation, and fears of transform be related to employee’s clutch for security (Strauss and Sayles 1972). Union provide a guarantee to employees by objection process that they will not be terminated illegally. Most of the non-union company should also provide a grievance process to increase worker security so that employees need not fear being terminated unfairly (Huston and Marquis 1989)

Work Value:

According to Ford (2009), a patient has returned to Aintree University Hospitals NHS Foundation Trust to thank nurses who potentially saved his life by spotting a serious heart condition during routine tests prior to an eye operation.

7.4 Pay:

Even though disappointment with payment has long been known as a key rationale for poor retention, a revision of study preceding the beginning of the current upgrading programme concluded that the connection between payment and retention is complex and is the most important one of several factors that may shape labour market behaviour (Buchan et al, 1998). The pay of nurses was disgraceful. Many were earning less than office cleaner (Baly 1980). In recent times, employment opportunities for women, the leading group in the nursing labour force, have been enlarged and this has decreased nurses’ relative income in relation to the labour force as a whole ( Sausman 2003). Subsequently, the observation that others may be earning more money for same or less liability may influence the decisions to leave nursing job for high-paid professions. One nurse reported that earning from nursing were less than a quarter of house hold income.(Seccombe et al. 1993).

Constant anxiety about the impact of frustration with payment on retention, integrated with the observation that a new career arrangement was required to substitute the clinical grading system, lead to the beginning of a new payment scheme (NHSE 2002). NHS Plan document (DH 2005a) reported that new higher pay scheme for most NHS staff was developed and might be launched over the next two years. Recent trends in nurse pay reflect developments in the three components of NHS nurses’ pay ( Seccombe and Smith 1996) These components are

The review body award which updates the whole NHS nurses pay structure by a fixed percentage amount.

An amount determined by local negotiation

An annual incremental increase reflecting individuals’ progression within their clinical grade.

According to (DH 2006), it has been discussed that pay renewal provides a more transparent method of reward and staff development It has long been proven that there are some areas in UK especially London and South-East where costs of accommodation are very high. Accommodation factor forces those people who work in public sector with low salaries, including nurses, to seek job elsewhere. This had directed to the beginning of various inexpensive housing proposals (Hutt and Buchan 2005) even though the result of these and other such proposal has yet to be assessed carefully for better retention strategy.

7.5 Moving to graduate Workforce:

Another significant side of the nursing retention challenge is the argument about whether nursing should turn into an all-graduate profession at the aim of registration. From long time some healthcare occupations like medicine and pharmacy had an all-degree route to registration, and others like physiotherapy have recently joined them. There is a argue about whether nursing should go for it or not. According to (Hayward 1992), low minority of nurses had finished their education to degree standard through a four-year course from the late 1960s.The Royal College of Nursing focus on nurse education expressing that every nurses should be educated to degree standard at registration; a position also favoured by Heads of University departments for Midwifery, Nursing and diverse constitutional and Health Visiting bodies. Yet, this observation is not commonly held and to be truth, the college motion debate on the move to all graduate entry was closely defeated at the yearly meeting in 2003. (Robinson and Bannett 2007)

According to UKCC (1999), In the 1990 a lot of universities started offering three-year nursing degrees. Then these offers were increasingly expanded and seven per cent of qualifiers were successfully graduates in England by the end of 1990. Both the diploma and the degree programme were offered in England. On the other hand, as module of the revision of pre-registration and post-registration nursing education projected in ‘Modernising Nursing Careers’, a review is to be completed of whether modification are required to the standard level at which the pre-registration nursing course is offered in the near future (DH 2006).

UKCC (1999) analysed that there was strong arguments in support of graduate entry include easy recruitment on the foundation that degrees are more preferable than diplomas to talented students. Fletcher (1997) added, generally a diploma required profession will not attract qualified students too much and standard degree level entry will increase the standing or status of nursing in compare to that of other occupational groups. Payne (1994) argued for graduate entrance saying that nursing would no longer employ from such a broad range of community backgrounds. Also (Hakesley-Brown 1999) added, more degree level employ may reject staff like healthcare assistants to get chance of study required for a registered nurse qualification. That causes total numbers would decline as the alleged complexity of studying for a degree may discourage latent applicants. Though it difficult to distinguish but a standard comparison of diploma and graduate applicants proved that the second one were a less diverse group than the first one in reality (Robinson and Bannett 2007).

7.6 Diversifying Recruitment:

The theme of growing diversity has been focused in the DH’s policy document for nursing (DH 1999). The main theme of that policy document was confirming the composition of the occupation more appropriately reflected the people it served and that the NHS authority meets up its recruitment requirements. Exact reference was given such as making training more available to those who seeking a second or third career with family caring commitments, people from ethnic minority groups, and those who wished to upgrade professional qualifications.

By observing regular turn down in the numbers of young people coming to the workforce and lack of NHS staffing (UKCC 1999), these policy documents were repeated by the UKCC in its re-evaluation of pre-registration education. Policies to extend diversity in nursing job were then consequently reinforced in the labour force proposals discussed in the NHS Plan (DH 2000b).

These were linked to the policy of extending participations in advanced education for those people who do not have conventional educational qualifications. The difficulty of recruiting a new diverse labour force focused in the debates that have been found in introduction of the three-year pre-registration degree in early 1990. Recently, in ‘Modernising Nursing Careers’, The significance of having several admission or entry points into nursing was discussed as a means of allowing applicant to take nursing professions as a second career (DH 2006).

7.7 Training:

The training opportunities for clinical nursing staff are an issue of increasing importance within the NHS today. It is held that the need for nursing staff to undertake further training after qualification is important for three major reasons. According to Beishon et al.(1995) First , by ensuring that they update their clinical nursing skills at regular intervals, they will more likely to continue deliver high quality of patient care .Finally, training is of crucial importance to nursing staff and their chances for further career development. The UKCC hopes to increase the amount of care given by qualified nursing staff than unqualified staff.(Beishon et al.1995)

7.8 Work life balance:

It has long been known that allowing nurses to accomplish a balance between working and daily family life is a key feature in getting better retention (UKCC 1987) . It has been a important feature of the recent policy programme. Plans include the establishment of system such as self-rostering that allows staff to better arrangement their social and family life during working periods. To motivate the employee in workplace, main interest has spotlight on combining work with caring for family and particularly children. Willis (1991) analyzed that Before the 1990s, the NHS was known as neither a woman-friendly nor a family-friendly organization. According to DH (1999), from the late 1990, plans to alter the bad impacts of associating work and family life on retention turned into vital issue to the human resources agenda for every health professionals.

The NHS strategy that launched Working Lives Improvements Initiative where NHS employers had to show strong commitment to more flexible working conditions like reducing hours facility, flexi-time, career breaks for higher education and an allocation of leave to look after family members when sick or facing any other serious problem. In addition, more funding was allocated to expand NHS financed and childcare provision with a goal for on-site nurseries, offering suitable hours, weekend coverage, bank holiday, emergency places and after school holiday play scheme.

Previous study proposes that the using of NHS financed childcare option is depending on problems faced by nurses. Waters (1997) said , The Royal College of Nursing research on the topic and conclude that even though one third (33%) of nurses had childcare facilities but only 5% used them. Potential reasons were found from a tiny qualitative survey of 22 nurses that found, this was because of logistics shift work (Morris 1995). Whittock et al (2002) supported by saying that same story come out from a later learning of 3 trusts outside the London.

Robinson et al (2003b) said, a study of one eighty one nurses in England also found that incompatibility with shift hour patterns was a cause for not using nursery facilities. Some people don’t take the nursery facility because they want their child to be cared by family members with husband/wife or child’s grandparents featuring most often.

Plan has been taken to facilitate combining work and family life. Also interest has been focussed to the impact of career breaks and duration of part-time job on career development. The majority of nurses come back to part-time posts after taking motherhood leave or a break for childcare which often led to a demotion or downgrading of position as part-time posts are considered in lower grades job.(Martin and Roberts 1984).

Reducing discrimination in career progression related with family commitments was the focal point of a policy document described in DH(2000a). This report suggested that employers must confirm that healthcare professionals who change their working style or shift pattern after motherhood leave or a career break or any other leave for family problem are kept at the same rank or grade. Further research (Robinson et al 2003) has reported that part-time hours remain the favourite choice after come back from a break but that a majority of employee return or join to the same grade post.

On the other side, a research (Davies and Rosser 1986) reported that people who work full-time make much faster career advancement to senior grades than those who have break or work part-time. This has been the topic of argue, focusing around the question as to whether women who don’t work full-time are giving more priority to home and family than to job and career development (Hakim 2000). A revision of these argues showed in a research paper that emerged from an previous NRU research of registered general nurses’ come back to work after motherhood leave which proved that nurses coming back to work part-time at their desired shift were stirred by career progress and job reasons rather than by lifestyle and economic needs (Davey et al. 2005).

Chapter 3

Research Methodology

This chapter illustrates the total research plan and strategy to conduct the research. This chapter is broken down into four parts consists of research process, research strategy, data collection and data analysis.

3.1 Research Process:

Research process is the master plan of any research. It involves six stages for successful completion of proposed research. The following model of research process presents research as a neat, orderly process, with one stage leading logically on to the next stage.

Choosing a topic and searching the literature

Reviewing the literature and defining the research


Designing the research and writing the proposal

Collecting the research data

Writing the final research report

Analysis and interpreting the research data

Figure 3.1: Research Process

Source: Collis and Hussey(2009, 10)

3.2 Research strategy:

The research strategy will be a general plan of how the research questions will be answered. The importance of clearly defining the research questions cannot be over emphasized. It will contain clear objectives, derived from research questions, specify the sources of collecting data and consider the constraints that researcher will inevitably have (for example access to data, time, location, ethical issue). Collis and Hussey(2009, p4) said research strategy can be classified according to the:

Purpose of research-the reason why it was conducted.

Process of the research- the way in which the data were collected and analysed

Logic of the research- whether the research logic moves from general to the specific or vice versa

Outcome of the research- Whether the expected outcome is the solution to a particular problem or more general contribution to knowledge

3.2.1 The Different Research Strategy:

There are several research method. Researchers chose any one of them to carry out their research objective. Some of these are inductive approach and some are deductive. Researcher has to find out whether the chosen strategy is appropriate for particular research questions. Experiment:

Experiment is a classical form of research that owes much to the natural sciences, although it focuses strongly in much social science research, particularly psychology. (Saunders 2003, p.91). Survey:

The survey strategy is usually related with the deductive approach. It is popular and common strategy in business and management research. This research allows the collection of a large amount of data from sizeable population in a highly economical way. Often obtained by using a questionnaire, these data are standardized, allowing easy comparison. According to Collis and Hussey(2007) survey methodology is designed to collect primary and secondary data from a sample with a view to collect primary or r secondary data from a sample, with a view to analyzing them statistically and generalizing the results to a population. Case Study:

Robson(2002, p.178) defines case study as a strategy for doing research which involves an empirical investigation of a particular contemporary phenomenon within its real life context using multiple source of evidence. This strategy will be of particular interest to researcher if researchers wish to get a rich understanding of background of the research. Grounded theory:

Grounded theory (Glaster and Strausss 1967) is often thought of as the best example of the inductive approach, although this conclusion would be too simplistic. It should be better to think of it as ‘theory building’ as a mixture of induction and deduction.

In grounded theory, data collection starts without the formation of an initial theoretical structure. Theory is developed from data collected by series of observations. These data lead to the generation of predictions that are then tested in further observations which may confirm, or otherwise, the predictions (Saunders et al 2003, p.93). Exploratory studies

Robson (2002, p.59) said exploratory studies are a valuable means of finding out ‘what is happening to seek new insights; to ask questions and asses phenomena in a new light’. It is mainly helpful if someone wish to explain his understanding of a problem. There are three most important ways of conducting exploratory research.

A search of the literature;

Talking to experts of the subject

Conducting focus group interview;

The aim of this type of research is to look for patterns, ideas or hypotheses, rather than testing or confirming a hypothesis (Collis and Hussey 2009, p 5)

Its great benefit is that it is flexible and adaptable to change. If researcher conducting exploratory research he must be willing to change direction as a result of new data that appears and new insights that occur to him (Saunders et al 2003, p.97).

3.2.2 Chosen Strategy:

Exploratory study will be used to carry out this research. This strategy was followed to conducting interview (Nurse Manager) interview. Previous research on retention of NHS staff will be considered. This strategy was selected because it matched with the research objectives. Researcher wanted to find the retention factors. It can be supported by Collis and Hussey(2009, p.5).

He said exploratory research is an interview among staff in a particular company to find out what motivates them to increase their productivity. Researcher of this paper also tried to find out factors that retain the nurses in NHS. Also survey strategy was followed to run questionnaire survey on nurses. Survey strategy was very important for the researcher to identify the factor of nurse satisfaction. This strategy was used to get the overall view of the nurses about NHS

3.3 Data Collection

Both primary and secondary data were collected during the course of the research. Primary data was obtained through interviews to managerial staff and questionnaire survey on Nurses of NHS. Secondary data will be collected from journal and other’s research.

3.3.1 Semi structured Interview:

The recommendation of Byrne (in Silverman 2006, p.114) was followed which suggested that “qualitative interviewing is particularly useful for accessing individuals attitudes and values”. Because of exploratory research, semi structured interview was chosen. Semi structured interview helped the researcher to identify the factors that affect the nurse retention in NHS.

Also, Easterby-Smith et al. (1993, p.73) defined that interviews allow the researcher to “understand the meanings interviewees attach to issues and situations”. Therefore semi-structured interviews, were used as they allowed the researcher to ask questions and follow up on points that needed more discussion. Nurse Managers were interviewed to carry out the research.

3.3.2 Questionnaire Survey:

The greatest use of questionnaires is made by the survey strategy. However, both experiment and case study research strategy can make use of these techniques. There are various definitions of questionnaire. Some authors reserve it exclusively for surveys where the person answering the question actually records their own answers. Others use it as a more general term to include interviews that are administered either face to face or by telephone.( Saunders et al 2003, p.280).

Here questionnaire survey was used to get the overall opinion of the nurses about their dissatisfactions.

3.3.3 Design of Questionnaire:

The design of the questions is very important to conduct the survey. The main aim of design the questionnaires are to find out what the target group thinks about the problem. To design the questions the steps were followed showed in figure 3.2. Question design is concerned with the type of questions, their wording, the order in which they are presented and reliability and validity of the responses (Collis and Hussey 2009, p.192). It is essential to test the questionnaire. Family friends are asked to play the role of respondents to test designed questionnaire.

Researcher designed survey questionnaire based on problems and retention factors like payment, work life balance, workload and training etc. Then questions were presented in a order. After testing appropriate distribution method is selected. It is also confirmed that questionnaires are returned. The last step was conducting validity and reliability.

Design the questions and instructions

Determine order of presentations

Write accompanying letter/request letter

Test questionnaire with a small sample

Choose method for distribution and return

Plan strategy for dealing with non-responses

Conduct tests for validity and reliability

Figure 3.2: Designing Questionnaire

Source: Collis and Hussey(2009, p.192)

3.3.4 Distribution Method:

There are number of distribution methods, each with different strengths and weaknesses. Cost is often an important factor and the best method for a particular study often depends on the size and location. Collis & Hussey (2009, p.193) describe the some method of questionnaire distribution. First one is by post- this is a commonly used method of distribution that is fairly easy to administer. Second one is face-to-face.

Here questionnaires of the research are distributed to the respondents in the work place, street and at their homes. And third one is Individual distribution- this is a variation of group distribution. If the sample is situated in one location, it may be possible to distribute, and collect, the questionnaires individually.

3.3.5 Chosen distribution method:

Face-to-face distribution method was followed to conduct the survey .Though it is time consuming but often very useful if sensitive or complex questions need to be asked. Advantage of this method is response rate can be fairly high. Moreover there is no risk of non-response bias. on-response bias is very critical for research. It is always seen in postal survey. Some people don’t send back questionnaires. As a result the collected sample data may not represent the target population. Researcher of this paper used this method to get 100% response.

3.3.6 Types of questionnaire:

The questionnaire survey will be done on the general Nurses of the NHS. The format of the question was combination of multiple choice and likert (agree/disagree). For this survey 30 nurses and 2 nurse manager are targeted. The Questions will be based on current retention problem.

Sample question:

Do you support the view that you are paid low in compare to other profession and to meet your responsibilities payment should be increase?

a) Agree b) Disagree c) Strongly Agree d) Don’t Know

3.3.7 Validity and reliability:

Reliability is concerned with the findings of the research. The findings can be said if someone else repeats the research and obtains the same results. Validity is also important and is concerned with the extent to which the research findings accurately represent what is happening in the situation; in other words, whether the data collected represent a true picture of what being studied.(Collis and Hussey 2009).

Here re-test method is used for reliability and validity. In this method the questions are asked from the same people. Responses for the two times and provide the same set of data is the proof of reliability.

3.3.8 Target group:

The target group for the researcher was Nurse Managers and nurses. For conducting the survey 2 nurse manager and 30 nurses were selected from NHS hospitals.

3.4.9 Ethical Issues

A number of key ethical issues take place across the stages and duration of a research project. Once participants have agreed to take part in research, they still maintain their right to privacy. This means that they have the right to withdraw their participations, and they may refuse to take part in a particular side of research.

Once promises about confidentiality and anonymity have been given it is of great importance to make sure that these are maintained (Saunders et al 2003, p.135). So during the qualitative research ethical issues were applied with care so that researcher behaviour remains within suitable and acceptable restriction. The following issues were considered during the research:

-In face-to-face interviews, overzealous questioning and pressing participant for a response were avoided.

- Any questions were not asked that is demeaning to the participant.

- During the survey or interview any personal or organizational data were be disclosed.

3.4 Data Analysis:

During the research, both quantitative and qualitative analysis was carried out. Analyses of quantitative and qualitative data are systematic methods of doing the research or find out the research objective.

3.4.1 Quantitative:

Quantitative data can be divided (Saunders 2007, p.409) into two distinct groups Categorical and quantifiable. Categorical data refer to data whose values cannot be measured numerically. Suppose if the question is asked from a nurse manager on Dress-code. The answer will be descriptive not numerical. However, quantifiable data are measured numerically. Here the data collected through survey were quantitative data.

During the quantitative data analysis first the data were categorised whether it is quantifiable or categorical. The coding will be done based on category. When coding was completed then data was entered into the computer. Then data were analyzed to get intentions and views of nurses about their job. After that retention factors were identified and linked it to the academic literature.

3.4.2 Qualitative:

Qualitative data refers to all non-numeric data or data that not been quantified (Saunders 2007, 470).The qualitative data need significant analysis. Most of the answers that researcher got from the interviews were not quantitative data or numerical data. So, to analyze the interview answers it was required to do the qualitative analysis. Also the qualitative data were analyzed to achieve the aim of this research.

The interview answers were analyzed through an approach based on exploratory research.

This method was preferred because it was more consistent with the aims and objectives. It can be supported by Saunders et al.(2003) who believe that if someone is doing exploratory research he must be willing to change his direction as a result of new data that appears and new insights occur to him.

The interview questions are categorized. Each interview was thoroughly examined against these to identify the factors that affect the nurse retention. These were then comparing to the academic literature in order to link back to theory.

Chapter 4

Data analysis

4.1 Introduction:

This chapter is designed to analyze the data collected from interview and survey. Each survey question is analyzed to find out the problem that lies in retention. Survey question’s answer are analyzed and represented using bar and pie graph. Interview answers were observed and compare to the survey results. The approach was therefore to re-read the interview answers constantly in order to discover any patterns and significant details. Then the data are categorized and compared with turnover factors. Each interview was examined against these factors and any patterns which emerged were identified and noted. These were then examined against the established academic literature in order to link back to theory.

To carry out this research 40 nurses are requested to participate in the survey. The response rate (75%) was good enough. 30 nurses were agreed to participate. Though the samples are small but they were selected from different department. So, they are able to answer the research questions very well.

4.2 Quantitative Analysis:

4.2.1 Motivation:

Motivations are very important in NHS hospitals to keep skilled nurses. To find out the motivators, the participants are asked to answer the question

Q. what are the motivations to keep you in nursing job?

The issues presented in this section emerged in the analysis of data. These include issues of meaningful work – for example, how nursing and caring for people is rewarding and sustaining. 17 % (Fig:4.1) of nurses answered that rewarding is a great motivator to retain them. Relationships at work were identifie

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