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Recruitment and retention of nurses: a ‘micro’ not a ‘macro’ problem

Thomas Kohut, a senior consultant at Uscreates and speaker at the upcoming Private Healthcare Summit, has been working alongside dozens of nurses over the last 12 months. He shares some insights on what really keeps them motivated and some guiding principles to bear in mind when faced with large numbers of nursing vacancies and high staff turnover.

According to the Royal College of Nursing, there are currently 24,000 nursing vacancies across the system. It is a common story amongst nurses: former colleagues who decided to do something new, or many fewer young nurses coming through the system. For some, particularly politicians, the root cause of the problem – and the potential solution to this recruitment and retention crisis – lies around money.

Of course, it’s the job of politicians to look at the big picture, and make promises about system-wide levers they have at their disposal to pull, like pay levels. But does this focus on the ‘macro’ picture give an accurate reflection of the problem facing our health and care system?

How much our society wants to pay public servants working on the frontline of healthcare remains a political decision. And a contentious one. It’s true that part of feeling ‘valued’ at work is about how much your boss is prepared to pay you for doing that work. However, Uscreates’ work with a variety of clients around this dual challenge of recruitment and retention has revealed that more often than not, the macro economic and political environment (including the amount people get paid) is not the primary reason why people choose to work in healthcare, and also why they choose to stay or leave their healthcare job.

In Thomas' view, we should be talking separately about the recruitment and retention challenge, and the issue of pay. Essentially, if the pay cap in the NHS were lifted, as much as that might be ‘the right thing to do’, he is not convinced that the staffing challenges in the NHS would diminish all that much.

The reason Thomas is not convinced that increasing pay on its own would work is because it misunderstands nurses as professionals, and what motivates them.

In working alongside dozens of nurses over the last 12 months across a number of specialisms (mental health, community nursing, emergency care, etc) what is striking is how varied their motivations are: people choose nursing and continue to work in a particular context because of a variety of internal, external and social motivators including:

  • Enjoying real autonomy in their role, being trusted by managers
  • Feeling empowered to tackle the problems they face day to day
  • The positive effect of working in a happy and fulfilled team (and the social rewards that come from that)
  • The ability to grow and develop as clinical professionals
  • Productive communication and interaction with their managers
  • Flexible working patterns that suit their lives
  • Being told they are valued, and seeing the impact of that (not just around salary)
  • The challenge of a high-pressured environment

No matter how much some nurses are paid, if they aren’t able to experience the above, they will start looking for new work at a different provider, or indeed leave the profession altogether. Incidentally, over-simplifying nurses’ motivations to ‘wanting to care for people’ also underestimates and misunderstands nurses: they are first and foremost driven clinical professionals.

Uscreates have been helping a number of clients across the healthcare system to tackle this challenge. The Uscreates approach has started with the principle that, only by going right to the front line to understand in as much detail as possible the lived experience of staff, will the challenge be properly understood and potential solutions start to emerge. The problem certainly isn’t uniform across the system. It isn’t even uniform within one hospital. You may have two wards side by side, nurses paid the same on each, and one with significantly greater staffing problems. Which is strong evidence that the problems are much more local, and connected to the experience of working day to day on a ward or out in the community, and everything that entails.

However, whilst solutions may be different in each setting, there are some guiding principles that healthcare organisations should bear in mind when faced with large numbers of nursing vacancies and high staff turnover:

1. Understand the ‘micro’ problem

Look at the data, but don’t infer too much from it without getting to the detail of the lived experience of staff. Ethnographic-style research, that shadows nurses rather than consults with nurses, is the best way to understand the challenges they face. Live it with them, and so much more comes into focus.

2. Don’t underestimate the impact of human interaction

Whilst nurses do face challenges at work that are very specific to their profession (shift patterns, impacts of staff ratios etc) their ‘difference’ can be over-emphasised and often gets in the way of making basic improvements to the job, such as how people communicate with each other. The high-pressured environment of a secure mental health ward, for example, amplifies the negative impact of a tense interaction with a colleague compared to the same interaction in an office (or even in a less acute clinical setting).

3. Don’t be tempted by grand gestures

It is all too easy to think that a positive staff experience is about cosmetic improvements that are easy to implement. Good, comfortable, well-designed staff communal areas are important and a worthwhile investment, but no-one ever stayed in a job because the sofas in the staff room were comfy.

4. Focus on empowerment

Across Uscreate's public sector clients, those on the front line are being asked to deliver more for less whilst at the same time given the burden of ‘problem solving’ and asked to come up with ‘innovative’ ways to respond to the changing service user group. This isn’t easy, and will often require investment in capacity building and culture change. However, once this culture change happens, the knock-on effect of improved staff self-confidence and morale on retention could be significant.

5. Remember nurses are clinicians first, carers second

Nurses need to feel empowered as clinical experts, and need access to the latest innovative thinking and decent training in order to feel valued by their employers. They gain deep personal satisfaction from caring for others, but will truly connect to their employer when they gain satisfaction from growing as professionals.

So nurses are driven clinical professionals, who “care for people” but also look for a workplace that meets their human need of recognition, empowerment, and work-life balance. And while money is a motivator, it’s not their sole reason to get up in the morning.

About the Author

Thomas is a Senior Consultant at Uscreates. He uses design, collaboration and creativity to solve organisational problems, rethink services, and develop campaigns, behaviour change and engagement programmes. He will be speaking about "New models of staffing and recruitment" at the Private Healthcare Summit on 20 June 2017.

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