It's not an easy job to manage nurse intake and retention at a hospital in the UK.
A massive nurse shortage is affecting the NHS, with 117,000 job vacancies in the overall health and social work sector across the UK.
While most commentators insist that more funds and better workforce management are required, we wonder: Is there anything that can be done at trust or hospital level to retain more nursing staff?
In our research, we aggregated testimonials of a senior hospital manager, a nurse, anonymous sources, online research, and best practices from the private sector. The suggested measures can be implemented both at ward as well as hospital level. We are focusing on measures that are free or very low cost to implement.
Towards the end, we provide some bonus ideas on how to retain nurses who relocate from abroad.
The nationwide nurse shortage is hardly news. Trusts make up for the shortfall by using expensive agency staff and by hiring from abroad.
At the same time, new entrants into the profession are disillusioned: The Good Governance Institute reports (PDF) that only 82% are still working as a nurse three years after qualification. Given the cost of £70,000 to train a nurse, this is a depressing number.
The biggest need for action undoubtedly lies at government and NHS level.
But we wanted to explore the topic of measures an individual trust or hospital manager can take to maximise staff retention in his or her area of influence. It's analogous to the question "How to dress appropriately in harsh weather conditions".
In our list, we focus on less self-evident measures and assume that some best practices, such as a buddy system, excellence awards, employee of the month etc, have been put in place. (They indeed have been, in all the trusts we spoke to.)
1. Let existing nurses interview new candidates
Asking existing staff for their input on new colleagues is empowering. It makes them reflect on your organisation's values and think if a new person fits them. "Part of how you find those qualities is to have colleagues interview and select who they want to work with", says Ann Scanlon McGinity, Chief Nursing Officer at the Methodists Hospital in Houston, Texas.
It heightens a sense of ownership of, and responsibility for, the team culture.
Admittedly, this places additional strain on a nurse's schedule. Many nurses are so busy during their shift that there's hardly time for a coffee break, much less 30 minutes to ask a job candidate probing questions. Therefore, we suggest that you ask for their contribution on a voluntary basis. Framing it as career advancement can also help. After all, interviewing is a valuable skill. Also, emphasise how important it is for the team culture.
You can make things easier by scheduling interviews to the beginning or end of a volunteer's shift, or whenever they prefer. The candidate will surely oblige with uncommon interview times.
Thorough coaching throughout the process is important:
Before the interview, go over the questions the nurse is planning to ask and challenge them if you think a question is not useful. Tell them what they can't ask - such as questions about personal matters, e.g. relationship status.
Initially, conduct the interviews together with the volunteer (two interviewers on one candidate) to gauge their style of interviewing.
After the interview, a great learning technique is to ask the nurse first what they thought of the candidate before you give your own opinion. It forces them to make up their mind and to clearly articulate their position. If you disagree with them, it also compels them to stand their ground versus a senior colleague, which is also a useful skill to develop.
When a nurse thinks a candidate is not suitable but you think they are, it's best to defer to their opinion, especially if they defend it emphatically. It would be a big morale-sapper to ask someone to interview a candidate and then to overrule them - it's like their opinion doesn't really count. If you feel strongly that the candidate is indeed good, argue it out. Make sure you win the nurse over through the merit of your argument, and not because of the seniority of your position.
Many private sector companies have a principle of unanimity, where all interviewers either have to give a strong or weak yes with at least 50% strong yeses. Every interviewer has a veto: A no from just one interviewer dooms the candidate.
2. Turn experienced nurses into Q&A powerhouses
A problem we uncovered in our research is the brain drain from hospitals. "City hospitals often find it easy to recruit newly qualified staff. As they get older and have families, they move to the countryside, which means that rural hospitals sometimes have an excess of more experienced people", says Rishi Das-Gupta, Director of Improvement at UCLH NHS Foundations Trust. "There's competition among hospitals to get the experienced nurses".
One way of dealing with this is to accelerate the knowledge transfer. Some hospitals reduce the experienced nurses' patient commitment in order to make them available for mentoring the juniors. Especially in cases where the buddy system pairs up inexperienced newbies with only slightly more experienced nurses, this measure can turbocharge the knowledge transfer.
This is mainly a measure to lessen the impact of experience drain. But it can also serve as a means of preventing attrition: If you make it clear to the junior nurses that this is an initiative of your hospital or ward, they might think twice to leave if they are enjoying the rapid learning curve.
3. Foster friendly rivalries between wards
Organise competitions between wards that reward improvements in desirable metrics (e.g. patient satisfaction, hygiene standards, Care Quality Commission or Ofsted ratings).
For example, the East Lancashire Hospitals NHS Trust has implemented a scheme where a team of inspectors visit wards unannounced, talk to staff and patients and rate the quality of the service. The findings are published so that patients can choose the best ward.
But you don't have to go that far. You can run a simple patient satisfaction competition where patients receive a link to an online survey that measures their satisfaction across different dimensions.
Youssef Hajjaj, nurse at the Airedale NHS Trust, which runs various team-based competitions (called the Pride of Airedale), says: "Even if there's no financial reward at the end of it, you're proud for the bragging rights. People are buying into it and are looking forward to it every year."
4. Provide individualised feedback and celebrate the successes
Diligently collect all patient feedback and regularly provide it to the staff in question.
Filter the positive feedback and present it to each team member during work anniversaries, and read the best of it out loud for everyone to hear.
5. Create a peer recognition programme
Allow staff to nominate a peer who has done something above and beyond their call of duty. The would-be recipient's boss evaluates the merits of the nomination and approves or blocks the nomination. The winner gets a prize that can be accommodated with your budget. Even if the prize is just a mention and round of applause at a quarterly get-together, it will still leave an impression.
It is important that the criteria for this be clearly spelled out and that the nominee's manager have power of veto and truly only recognise those whose work has cleared a certain threshold of "wow". Nominating someone because they are friendly with patients doesn't cut it. For reference, read up about Google's (as in: the company Google) peer bonus system.
6. Conduct regular stay-on interviews
Most organisations run exit interviews to understand an employee's motivation for leaving.
Wouldn't it be better to do regular in-depth check-ins with employees to get a feel for where they're at in their career? Doing a "stay-on" interview every six months allows you to be better at taking someone's pulse and see how satisfied they are with their role. That way, you catch potential leavers earlier.
7. Act on feedback
This one sounds obvious, but few do it well. Organisations are usually good at gathering feedback, but less good at acting on it. This doesn't mean that you have to solve every problem. What nurses will appreciate, though, is if you share your priorities along these lines:
"Team, you mentioned 7 areas of grievances with me. Two of these can be resolved by us collectively if we do x, y and z. Of the remaining five, I will have bandwidth to tackle two this quarter. It seems that A and D are the most pressing issues. I'm afraid we'll have to live with B, C and E but we'll revisit them next quarter."
This level of transparency is a better approach than doing nothing, hoping that the problem will go away or that people forget. Your team understands that your day also only has 24 hours and will acknowledge you for having shared your thought process.
8. Subtly encourage flexibility
A person who spoke with us on condition of anonymity expressed their frustration at the high rate of "hour counters" within the profession: Nurses who work their contractual number of hours and nothing more. "It's hard to make something happen in terms of organisational culture if the person you speak to starts packing their things mid-sentence just because the clock has struck."
As long as you don't engage in favouritism towards staff who display flexibility, it is acceptable to hold up those who did something beneficial for the team outside of their contractual working hours and present them as examples worth following. This can be someone who took time to interview job candidates, or someone who stayed on after their shift to help decorate the ward for a staff party.
As in any other job, a nurse gets out of a team what they put in. If all you do is work to rule, without any extracurricular contributions to the team, your work environment will be less well off than if you contributed some of your spare time.
Commending team members on going beyond their statutory obligations is a good way to encourage a sense of ownership.
BONUS: Ideas to retain nurses who relocate from abroad
International relocation comes with its own set of retention challenges.
Many nurses move temporarily to send some money back home, and return after a year or two. But there are plenty who come with an open mind, ready to settle if they like their new life here. You can support them in the following ways:
1. Give extra encouragement to speak up
A healthcare expert who spoke on the condition of anonymity, told us: "Asians and Southern Europeans tend to think in hierarchical terms, and rather than speaking up about something they're not happy with, many nurses from these countries just live with their grievances because they are uncomfortable confronting their boss. This can range from not having the right equipment to being bullied."
Therefore, to minimise attrition in the earlier stages of an immigrant's stay, before they have found friends and underwent cultural acclimatisation, it's important that you give them extra attention, inquire about their work satisfaction and encourage them to speak up when things are not going well, for whichever reason. Better to ask too often than not often enough.
Having regular staff meetings where things get discussed directly will also impress upon the new arrivals the culture of openness.
2. Help them settle in socially
Most immigrants come to the UK without having many social connections, especially when they are going to work outside of large urban centers.
So help them make friends! With that, we don't mean to parade them around the hospital and foist them onto unsuspecting colleagues. But how about you put together a guide on getting social in their new environment?
If this sounds daunting, it's not.
Simply google "How to make friends in a new city", read a few articles and create a reader's digest of the best bits. If you have a mailing list of your staff including the nurses (if you don't have one, create one), ask people to share stories how they found friends settling in a new city generally or in your specific geographic area, including specific groups, meetups, or events to go to. Collect and share a list of friend-making apps.
Compile all this into a 10-15 page document, print it out, throw in a fun book about English culture - and you have a cheap welcome gift with high gratitude potential.
Foreign staff tend to be cash-strapped when they arrive. Some trusts provide short term loans to cover settling-in costs. E.g. a few Central London Trusts provide a loan to help with buying the first season ticket for the daily commute.
4. Consider installing temporary lock-ins
The private sector abounds with examples of lock-in periods. And justifiably so. If an employer supports an employee financially (e.g. for education or relocation), it's fair that the employee is required to stay on for a certain time and can only leave if they repay all or part of the investment in them.
But the concept is alien to the British healthcare sector. According to Rishi Das-Gupta of UCL, "we have been reluctant to do this as there is a need to ensure staff feel safe to speak up or leave if their conditions are unsatisfactory or care is unsafe."
This concern can be easily catered for if you withdraw the lock-in when the employee has raised a justifiable case of poor or unsafe working conditions.
So do consider, if your authority permits, implementing contractual lock-in periods for employees who receive some form of subsidy from you - either the above mentioned loan or further training that helps them with their career progression.
By taking some of these measures, we hope that you will be in a better position to retain more staff and reducing attrition.
Talk to us about providing relocating nurses a truly fine and jolly welcome. Contact us at firstname.lastname@example.org
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