Strategies for Addressing 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 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

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

2.1 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.

2.2 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:

2.2.1 Retention

is the percentage of employees remaining in the organization. High levels of retention are desired in most job groups.

2.2.2 Turnover

On the other hand turnover is opposite to the retention, refers to the percentage of employees leaving the organization for whatever reason(s).

2.2.3 Turnover rate

Refers to the rate of individuals leaving.

2.2.4 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.

2.3 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)

2.4 Cause of leaving

2.4.1 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.

2.4.2 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.

2.4.3 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.

2.4.4 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.

2.5 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.

2.5.1 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.

2.6 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).

2.7 Retention Strategies

2.7.1 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.

2.7.2 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

2.7.3 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.

2.7.3.1 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.

2.7.3.2 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.

2.7.4 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.

2.7.5 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).

2.7.6 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).

2.7.7 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)

2.7.8 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

Problem

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.

3.2.1.1 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).

3.2.1.2 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.

3.2.1.3 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.

3.2.1.4 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).

3.2.1.5 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 identified as vitally important, and relationships with managers and other nurse colleagues in particular resulted in satisfying and enjoyable places of work for some, and poor and demoralising work environments for others. Nurses in NHS trust valued the idea of improvement – both personal development and progress, and making changes in the work environment to make it a better place to work and better for patient care.

Fig: 4.1 Motivators of Retaining Nurses

46% of nurses said that relationship with manager is key motivator to retain nurses. Another group of participants told that they expect great support from their colleagues. That group was second highest in majority (27%). Finally, some participants support of their need to feel valued in the work they do – valued by patients, colleagues and indeed the wider community. The role nursing plays in the organisation was particularly when money-saving initiatives were seen to reflect the lack of value placed on nursing within the trust.

4.2.2 working flexibility

Flexible working should not bring the end of nurses’ career expansion. If a job is provisional, with NHS Professionals, nurses still have the chance to improve skills and develop their future careers. Flexible working arrangement is very crucial for the nurses. At present it plays a great role to retain the nurses in their profession. To find out whether nurses getting working flexibility facility, the participants were asked to answer the following question

Q. Are you offered flexible working arrangement?

27 out of 30 said that they don’t get any flexible working shift. And rest of them said yes. So, about 90% of nurses are deprived from this facility which causes dissatisfaction in workplace.

Fig 4.2:- Flexible Working Arrangement

Nurses were like the people who wished to do the irregular extra shift in the evenings or at weekends to make some additional money.

How times have changed. Gradually more, nurses are selecting flexible working as a career, either as of their domestic conditions or as they want more diversity. Several permanent nurses are doing bank job as a path to get more experience of working in a diverse area of nursing or different kind of hospital to help them make a decision whether they desire to change direction or to get further experience to assist with a job application.

Chris Day, Director of Marketing and Communications at NHSP (NHS professional) said (Nursing Times 2009) only one-quarter of single parents had been offered suitable work shift other than through NHS Professionals, and approximately all of these were offered term-time contracts that were not flexible enough. Though demand of flexible working increased but it has not been offered acutely in the NHS until now.

Flexibility was always identified as a means to an end to earn additional money in the past. Flexibility now appears more of a lifestyle selection. People are actually choosing to work flexibly because they have no other way of working in the NHS.

4.2.3 Nurses’ Satisfaction

Nurse satisfaction is very important for NHS nurse retention. A question on job satisfaction was:

Q Are you satisfied with your current job?

Fig 4.3: Job Satisfactions

56% of Participants were not satisfied with nursing job. 17% said yes and rest of the participants denied giving any the opinion. So, the majority of the participants that were totalled 17 out of 30 suffering from dissatisfaction for various reasons.

Lewis et al.(2002) reported that nurses spend time performing functions not related to their professional skills, such as cleaning rooms or moving food trays. More pressure to take up management responsibility, taking nurses away from the direct care of patients.

Nurses spend much of their time doing things that should be delegated to others and not enough of their time doing what they are educated to do. This is frustrating and demoralising and accounts for at least some of the widespread job dissatisfaction in the profession.

4.2.4 Abused By patients

Q Have you or your colleagues ever been abused by patients or anybody else in workplace?

Fig 4.4 : Abused by Patients

16 nurses out of 30 said yes that means they are facing patient’s bad behaviours and 14 nurses said NO. Abusing or using bad words by patients can cause dissatisfaction. Later on which will bring the mental stress and compel them to leave the job. Researcher also found that other NHS nurses were also abused by the patients.

Janet reported (Lewis et al, 2002) that she worked as a nurse in the NHS for 18 years .She spent 15 years in emergency medicine department. She abused by patients several times.

She told after a frightening assault on her, she became concerned about her safety and that of her colleagues. She informed the management and said that she did want to working in emergency care if they were not provided with full time security. She was told that this expenditure could not be acceptable. She then left the NHS as soon as possible.

All non-union organizations should also provide a grievance procedure to increase worker security so that employees need not fear being terminated unfairly (Huston and Marquis 1989)

4.2.5 Work Pressure

Work pressure is very crucial factor to influence the nurses to leave the job. Work pressure creates the dissatisfaction which force the staff to quit. The survey result found that high work pressure level creates dissatisfaction and burnout.

Q. What level of work pressure do you experience in your workplace?

Fig 4.5: Work Pressure

40% of the participant said they felt extreme level of work pressure in work place. 33% said high level and 20 % said medium. So, majority of them were feeling the work pressure in their work place. Definitely work pressure causes dissatisfaction. It was discussed in literature review. Bratt et al.(2000) said work pressure factors which influence the nurses to leave the job. These factors include shift work, extreme noise, lack of space, lack of equipment and managerial pressure. Also Mc Vicar(2003) said that the main sources of stress are workload , coping with emotional demand of care and relationships between professional groups. However, Nurses feel stress and low morale when they work in environments like under-supported and under resourced.

4.2.6 Staff Shortages

Q. Do you agree that NHS has shortage of stuff?

In response to the question 27 % Participants strongly agreed and 56% only agreed. So in total 83% people supported the statement. Only 17% disagreed to the statement.

Fig 4.6: Staff Shortage

Staff shortages have both personal and original consequences and both aspects require attention. For individual staff shortage mean overwork and frustration from being unable to satisfy their personal care standards. For the organisation, the consequences are equally significant, with adverse effect for patient care, staff retention and recruitment. Staff shortages mean that nurturing, mentoring and teaching as well as formal training and development is sacrificed to more urgent needs

One cardiology nurse said that Staff shortages mean that although you are trying to do your best it isn’t good enough or to the standard you would like.(Newman and Maylor 2000, p 20 )

Another Nurse (oncology department) reported

“I haven’t had a break since I started this morning at 7.15 a.m and it’s now 2.30p.m At the moment we have staff, but they are so you can’t give them the responsibility. We are so short of experienced qualified staff. ”( Maylor et al 2000, p 28).

4.2.7 Poor Management

Management is a big issue to retain skill nurses in NHS. To get out staff’s view about their managers following survey question was asked.

Q. How do you rates the NHS Nursing Management?

Fig 4.7: Poor Management

In reply to this question maximum participant reported about the negative attitude of management. 18 people said management is poor that was maximum. No vote for efficient management. 5 people said normal. And 6 people don’t want to comment on management.

Maximum voted for poor management which proved that staffs were not happy with their management. Poor management make upset the skill staff and motivate them to leave the job.

Observations of poor management are pervasive and versatile. These bring range of HRM problem such as claims of harassment, uncooperative behaviour towards staff, bad discipline and a lack of admiration, terrible job environment (precisely work in flexible shifts and hours, strength of skill mix and personal security) and a technique of management seen as insensible, highly challenging, unhelpful.( Maylor et al 2000, p 29)

According to one observer reported in a research, the management are not seen in hospital. If someone complain and complain about problems but they are not heard. Patients complain and they don’t take any action. Also they never mind if the staff are abused. There is a lot of bullying from staff, which is never dealt with. She just experiences that there are many issues or problem that are never taken in consideration and have just remained the same for several years.(Newman and Maylor 2000, P 24)

4.2.8 Pay

Payment is very important to keep the skill staff. When staffs observe that they are less paid than other professionals considering the responsibilities then they decide to leave the job.

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

The result from survey clearly showed that staffs were not satisfied with their salary. 40% people think that they are paid low and salary should be increased. And this was supported by 50% staff who voted for strongly agree. So, in total 90% staff agreed on increment of salary. 10% didn’t care about payment.

Fig 4.8: payment

Pay is of course a major grievance. It is a pervasive concern and must be included in the sources of job dissatisfaction. Good pay is crucial to nurse. The most concise comments on the matter can be represented by one example. From literature it can be found that in recent times, employment opportunities for women, the leading group in the nursing labour force, have enlarged and this has decreased nurses’ relative earnings in relation to the entire labour force.( Sausman 2003).

One NHS staff said that the pay doesn’t match up to the job they do and another said it is frustrating when their friends are being paid more than him for doing much less important jobs (Newman and Maylor 2000, p 28).Increasing anxiety about the impact of frustration with payment on retention, united with the observation that a new career arrangement was required to substitute the clinical grading constitution, lead to the beginning of a new payment scheme (NHSE 2002).

Some times some factor force the staff to leave the job. One factor is high standard living cost or accommodation cost. This factor might influence the participant of this survey to support the payment increment. According to (Hutt and Buchan 2005), it has long been proven that there are some areas in UK especially London and South-East where cost of accommodation is very high. That factor forces those work in public sector with low salaries, including nurses, to seek job elsewhere. This has lead to the beginning of various inexpensive housing proposals even though the result of these and other such proposal on retention has yet to be assessed carefully.

4.2.9 Stay In NHS Nursing

Keep continue in NHS nursing is depends on the facilities that employees got. Except this other reason may exist. To find out the intention to working in NHS, the participants of survey were asked to answer the following question.

Q. why you want to stay in NHS hospitals?

Fig 4.9: Stay in NHS

Chosen career:

From the result it found that 7% of participant said they want to work as nurse because they chose nursing as career. This can be supported by other study (Maylor et al 2000, p10) where one NHS nurse said “This is my chosen career. I am good at it. I am not mediocre. I am good and nursing has always given me a thrill, a buzz and job satisfaction. Nursing is great.”

b. Convenient location:

36% people said they are working in NHS for convenient location. It can be argued that nearness of the hospital to a nurse’s home contributes to nurse retention. Also the trust is easily reachable by both private and public transport. Several of those who participate in survey lived locally and as a result spent less time travelling to and from job place. Working in the same area and hospital also meant that there was no need to learn new ways of doing things.

c. Family environment:

Some (13%) replies that family environment of workplace motivate them to stay in NHS nursing job. Family environment has a great influence on nurse retention In the research of Maylor et al.(2000, p 10) one staff said:

“It’s more for the unit; it’s got friendly staff. I don’t know if it’s for the Trust.”

d) No Alternative: 17% people doesn’t have any alternative other than nursing

So from the above analysis it can be found that convenient location and career are the main priority to stay in NHS.

4.2.10 Reasons for Leaving Nursing

Q. What is the worst side aspect of nursing?

40% participants said they are not valued .Appreciation is a great motivator to keep the skill nurses. If someone work hard but not valued then it will be mental depression for him.

One participant in a research said that lack of resources and devaluation of nurses’ roles, Often the views of nurses are not valued. Meeting cascade information down but nurses don’t have much of a say” (Newman and Maylor 2000, p 35)

23% people supported the public attitude towards them is worst side of nursing. As Nurses take care of patients they should not be abused by patients or anybody

Fig 4.10: Worst side of Nursing

Other research said Nurses are demoralised. The expectations of the public are increasing. They expect too much but don’t want to respect the nurses at all. People abuse the nurses and the management don’t take any actions. One nurse from cardiology said the way people look at you “You are a nurse” It’s such a put down (Newman and Maylor 2000, p 37)

17% people said working condition is the worst side of Nursing. And 20% didn’t say anything.

4.2.11 Career Progression

Q. Is there sufficient opportunity for you In NHS like career progression?

Around 70% said, there is not sufficient opportunity for career progression for them and 20% said yes and 10% said they don’t know. Survey clearly showed that staffs were not satisfied on NHS carrier development plan.

Every one has an intention to build a good career in his field. When there is sufficient opportunity for promotion, skill staff doesn’t have any intention to leave the job. That means proper career progression opportunity restrict the nurses to go for another job.

Fig:4.11 Career Progression

From the literature it can be found that carrier progression is another factor to retain nurses. Proper carrier path way motivate the nurses to give their best service. Donner and wheeler (2001) said that educators, employers and professionals should work for career development of nurses. To increase quality of patient care and meeting the service requirement, CPD (continuing career development ) is very important for career progress of nurses and retention

One (G grade paediatrics) said, I can only see another 2 grades in nursing. I am not going to do the same job for another 30 years (Newman and Maylor 2000, p 36)

4.2.12 Degree in Nursing

Q .What kind of degree do you have?

In response to the question only 30% said they have graduate degree and 70% said they have diploma degree. So most of the participants have no the graduate degree. It is very important to recruit graduate nurse. It will increase the job satisfaction of nurses. Fletcher (1997) added that standard degree level entry will increase the status of nursing in compare to other profession.

Fig 4.12: Degree of Nursing

4.2.13 Training

Q. Do you think that training you were given enough for you to carry out your job?

In response to this questions 47% said they training that they were given was not sufficient for them to carry out the job efficiently. 40% said training was ok for them. 13% don’t know whether training was efficient or not.

Fig 4.13: Training

Training is a very important factor for nurse dissatisfaction. Proper training can remove the dissatisfaction of nurses. According to Beishon et al.(1995) training is of crucial importance to nursing staff and their chances for further career development.

4.3 Qualitative analysis

Qualitative analysis carried out on some interview of nursing managers. Questionnaires were designed related to survey questions.

Q. Do you think that nurse payment is low in compare to other profession and their responsibilities?

One interviewee said nurses leaving NHS because low payment and payment should be increased to retain them.

Another interviewee said compare to working responsibility payment is good enough

So, payment is the main factor that influences the nurse to quit job. Payments motivate the today’s nurses very much. According to Susman(2003), the perception that others may be earning more for equal or less responsibility may contribute to decisions to leave nursing for better paid occupations.

Q. Do you arrange proper training for the nurses?

In case of training one interviewee said “actually we train the new nurses when they start their job.” Other said “training is very important for nurses. And we have enough facilities for training. Moreover if some one needs training we can arrange training for him.”

So training is very crucial for nurse satisfaction and confidence. Beishon et al.(1995) said training is important for ensuring that they update their clinical nursing skills at regular interval

Q. Do you think that you have shortage of skill nurses at this moment?

All Interviewee agreed on shortage of staff in NHS. Shortage of staff creates work pressure on other people. Other nurses have to work for long hours.

Buchan (2000) said that from 1990 to 1998 , the number of qualified nurses decreased by 80000. Work stress can be caused when nurses feel under-supported(Cameron and Masterson 2003)

Q. Do you allow nurses to work in flexible shifts?

One said “We do but sometimes its not possible to give flexible hours. We don’t have enough staff.” Another said “It depends, sometime it possible or sometime not. It depends on the available shift.”

So due to staff shortage nurses were not getting flexible hours. That is another major problem for retention. It has long been known that allowing nurses to accomplish a balance between working and daily life is a key feature in getting better retention (UKCC 1987)

Q. Do you support rewarding system or childcare facilities to motivate nurses?

To motivate the nurses rewarding system works greatly. Interviewee support the reward system to reduce the dissatisfaction but NHS doesn’t practise this strategy to retain nurses.

It has long been known that allowing nurses to accomplish a balance between working and daily life is a key feature in getting better retention (UKCC 1987)

Do you think that NHS should recruit graduate Nurses?

One interviewee reported that most of the nurses have diploma or joined in NHS as a healthcare assistant. He said NHS should go for graduate workforce.

Another said NHS can recruit graduate. Graduates have more academic knowledge of nursing than diploma holder. Robinson and Bennet (2007) said it is difficult to distinguish but in comparison graduate applicants were the less diverse than diploma applicant

Q Are the nurses abused at work place?

One said sometimes they are abused by patients. Another interviewee said nurses are not abused by colleagues or any staff working here. But sometimes they are abused by patients. Beishon et al. (1995) said, 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.

Q. Do you have enough facility for career progression of Nurses like promotion?

One interviewee reported that there is plenty of opportunity for career development for nurses. Another said they have the opportunity to be a senior nursing manager.

4.4 Key findings

Researcher of this study found many problems that were enough to influence the nurses to leave the job. The following are the key problems exist in NHS.

Payment

From both qualitative and quantitative data payment was found vital for staff retention. Due to high living cost, sometimes it is difficult for nurses to stay in same job in UK. A new career arrangement was required to substitute the clinical grading constitution, lead to the beginning of a new payment scheme (NHSE 2002).

Work life balance

Lack of Working life balance is another major problem for NHS to keep their skill staff. Nurses are not getting childcare facility. NHS was neither known as a women-friendly nor a family-friendly organization. (Willis 1991). Most of the participant (27) reported that they don’t get flexible working shift. From qualitative analysis it was found that lack of working flexibility exist in NHS. Plans to alter the poor impacts of associating work and family life on retention turned into vital issue to the human resources agenda for every health professionals (DH 1999)

Work pressure

From both qualitative and quantitative analysis it can be said that staff shortage is a major problem in NHS. Because of staff shortage other nurses feels work pressure. Work load on nurses due to shortage of staff creates burnout. Nurses are doing over time and their shift is not flexible. 40 % of nurses said they felt extreme level of work pressure in work place. Aiken et al (2002) reported that nurses with the lowest nurse- to-patient ratio experiences less burnout and dissatisfaction than those with the highest ratios. Buchan (2000) said that from 1990 to 1998, the number of qualified nurses decreased by 8000

Working condition

Working environment is not supportive for the nurses. They are abused by patients. That causes moral dissatisfaction of nurses. Majority (53%) of survey reported, they are abused by patients. 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

Work value

Around 40% people reported that worst side of nursing was not valued at work. From the qualitative data it was found that managers also support the system of reward for good work. Korman et al.(1981) said if a small reward results in desired behaviour, then a larger reward will result in even more of the desired behaviour

Recruitment

Most of the NHS nurses have the Diploma. They were not a graduate. Fletcher (1997) added, generally a diploma required profession will not attract qualified students too much and standard degree level entry will increase the status of nursing in compare to that of other occupational groups. Also diploma holders are not loyal to their employer.

Robinson and Bennet (2007) said graduate applicants were the less diverse than diploma applicant

Management and Motivation

Finally, Management is vital for nurse retention. Analysis result found that there is a gap between staff and management. Most of the participant reported that management was poor. Jeskins and Henderson(1984) demonstrated that managers’ personal motivations are the most important factor affecting their staffs’ commitment to duties and morale. Another issue found during the analysis that was proper training. Management should provide proper training to motivate the staff. Lacks of motivations always create moral dissatisfactions.

Career progression

From qualitative analysis it was found that there was a lot of opportunity for career progression. But from quantitative analysis it was found that there was not enough facility for career progression. Continuing professional development has an significant function in nurses’ individual career development and retention (UKCC 2001).

Chapter 5: Conclusion

The National Health Service in UK is struggling to retain nurses and has been trying to find better retention strategies for a long time. It is better for NHS (in terms of cost saving), to try to retain staff than recruit.

The better retention strategy is such an important issue which explains so many feature of the organization, especially the aspects of development in the parties, both the organization and the employees. These two factors are the parallel features and related to each other in any organization. So, required improvement in both parts would produce good and satisfactory output.

Even though a reasonable stage of staff turnover can be good for an organization, every organization should have a plan in place to retain highly skilled staffs that give it a competitive advantage. The result of not doing so can be very costly for the business and causes low staff morale, bad reputation on company and business loss.

The government has acknowledged and wanted to solve the difficult problems of recruiting and retaining skilled nurses. But even though the resulting national scheme, problems persist. Overall progress has been slow; staffs are not informed of the new chances offered to them (Smith and Seccombe 1998). He also added labour force issues are still nowhere near the top of the agenda for managers or trust boards. The new confederations have great potential to shape the agenda, but they are still in the initial level. 

The availability of a sufficient number of staff to meet patients' needs is essential to both the quality of care delivered and the retention of nurses who provide that care. During nursing shortages, this demand is often one of the most challenging for nurse administrators attempting to maintain care delivery standards and a stable workforce.

The lack of nurses is genuine, and expected to grow worse. Nurse executives, must act on a variety of fronts because no single plan will solve the crisis. Retention problems must be taken into action, particularly as associated to appreciating and recognizing nurses for their proficiency and allowing them with responsibility to contribute in the decision making processes regarding patient care. If NHS does not act properly, they will run the risk of experience a major staff shortage in the acute care setting, which will finally direct to deterioration in patient care

A nurse manager generally helps the medical unit by providing information, supporting with individual management, recruitment, and business arrangement or budget administration. Through unit business and management planning, nurse managers contribute to the strategic direction of the organisation, develop services to enhance core business and respond to changing organisational needs. It is vital for manager and future manager to be able to analyze, recognize and successfully deal with employee turnover (Mobley 1982).

In this paper researcher focus on the retention problem and address the question of how to improve the long-term supply of skilled nurses in the NHS. It was done by examining the factors which determine job motivation and satisfaction for NHS nurses.

The rational of this study was to gain some practical and theoretical knowledge on human resource management. NHS is running under staff and skilled staff retention was a big problem for them. So NHS was the great platform for the researcher to gain some knowledge on stuff retention examine the problem exist in NHS.

The aim of this research is to identify good practice in order to make recommendations on how the NHS could retain their skilled staff. To successfully complete the research and accomplish the aim proper research method was chosen in chapter 3. Here exploratory research method was used. This method is used because it is a simple method for new researcher. Robson (2002, 59) said exploratory research method is a valuable of finding out ‘what is happening to seek new insights; to seek questions and press phenomena in a new light’. Also survey strategy was followed for questionnaire survey. Both primary and secondary data were collected. Sources of primary data were interview and questionnaire survey. In interview semi-structured questions were asked. Multiple choice questions were designed for the questionnaire survey. Both quantitative and qualitative analysis was carried out.

To, remind the reader as mentioned in chapter-1 several objectives were designed to achieve the aim. The first one is review the literature on nurse retention. Therefore, in chapter 2 the researcher of this study reviewed the literature. Here working environment, Burnout, autonomy and work pressure were discussed as a cause of nurse leaving. Also how nurses face racism in work place by patients or colleagues were focused. Then some retention strategy discussed like motivating climate, career development in nursing, better working condition, payment, work life balance, proper training and recruitment.

Second objective was examining the existing problems in NHS. Data analysis was designed in chapter-4 to examine the current problem. Researcher found so many problems that were discussed broadly in that chapter. Third objective was recommending better retention strategies. So the recommendations were given later in this chapter.

Key findings:

This research provides strong evidence that job satisfaction is the single most important determinant of intentions to quit among NHS nurses. Majority of staff (56%) reported, they dissatisfied with their job which motivate their intention to leave the job. Only 27% said they were satisfied.

Shortage of staff and its consequences, in the form of stress, abused by patients, exhaustion or total burn out created in the weak working conditions were the greatest reasons given for considering exit from nursing profession. Behaviour and attitudes of patients together with a lack of promotions facilities are the other main reasons given for thoughts about leaving nursing. Newman and Maylor (2000, p35) reported that the reason of leaving nursing include the unrealistic expectations of nurses’ performance by patients, doctors and government, and the lack of career opportunities in nursing for those who wished to continue in clinical practice. 53% of participants said that they were abused by patients. So, the working condition was not supportive for the nurses.

From the analysis researcher got evidence of significant disappointment that exist in the nursing profession. One disappointment is low level of job satisfaction being reported by nurses. Researcher also got evidence that nurses’ perceptions of relatively low pay, compared to other public sector employees, leads to a significant influence on job satisfaction. Through data analysis it was found that 50% nurses reported strongly, they were paid low. In contrast, absolute pay is positively related to job satisfaction. Sloane and Williams (1996) said both absolute and comparative income has positive influence on the job satisfaction of staff.

Researcher also found that the flexible working environment for nurses is particularly important in explaining variations in job satisfaction. In reality, working a shift pattern which is not flexible, not being appreciated fairly in accordance with ones’ performance significantly reduces job satisfaction. So the lack of working flexibility arrangement is the major problem for the NHS management. Moreover, proper training facilities were also a major factor of turnover. It was found that nurses were not getting sufficient training to perform their job efficiently. Lack of training sometimes decrease the staff’s confidence and affect their quality of work. So they should get training at regular intervals. Poor management reported by majority of participants. There was no rewarding system to motivate the nurses. Management should motivate their staff to get best service from them. Managers can also create a motivating climate by being positive. Personal motivations are the most important factor affecting their staffs’ commitments to duties and morale ( Jeskins and Henderson 1984). Also lack of career progression facility was a problem for retention. Finally, It was seen that majority of nurses had the diploma degree. Fletcher (1997) added, generally a diploma required profession will not attract qualified students too much.

So, it can be concluded that job satisfaction may be generally more important than the attraction of outside labour. This analysis focused on nurses’ satisfaction with respect to aspects of their job, shows that demoralisation linked to poor career advancement opportunities, increased workload, payment and workplace relations are all important in determining quitting outcomes, but that dissatisfaction with payment and working condition has the largest quantitative affect. Overall these findings suggest that NHS retention policy should have an aim of improving skilled employee retention through increased pay for all nurses. NHS should focus on job dissatisfaction factors like abused by patients, working flexibility and work pressure. However, the evidence presented here suggests that efficient policy design must also concentrate on improving the career advancement opportunities available to nurses. The resulting improvement in retention would in turn reduce workloads. Special emphasise should also be placed on the needs of training specially nurses who have particularly low level of skilled.

5.1 Shocks for the Researcher

The researcher found from the analysis that sometimes staff are abused by patients. Public attitude should be changed about nursing. Nurses are the asset of this society. They take the good care of patients. If the nurses are abused in their work then it will bring moral dissatisfaction for them. Moreover, a lot of problems exist in NHS management but they never concentrate to overcome these problems.

5.2 Limitations

Nursing directors of NHS hospitals are facing difficulties in retaining their nurses. If these basic problems are not considered, NHS will keep on to lose experienced and nurses.

I had to face some difficulties to carry out the research and conduct the survey. But those problems were not easy to overcome. Because this research included many feature of Human Resource Management. Therefore, the researcher of this paper had to focus so many matters related to the topic. Some of the central limitations are specified below:

Because of limited time and other resources, research was limited to nursing profession and two interviews. This range could be extended to get deeper analysis.

I had to overcome many problems in order to obtain the interviews. Managing time and obtaining an appointment with the nurse manager was a very difficult task. More managers could be interviewed to get more valid data if there was more time allowed.

Without anyone’s help it was really difficult to complete the mission. If researcher got any support from friends, partner or anybody else then the study would be more organized.

To collect a full range of data from NHS was really a difficult task. Because they were very busy. For this purpose I had to make numerous phone calls to get the appointment and access to NHS. Of course nurses were busy with patients and I had to wait long time for the responses from nurses.

Conducting survey on almost 2 local NHS was really a tough job to do. And not all of them were supportive to response to the questionnaire.

Another problem was to select the NHS. Because the NHS was chosen from London, so, they may not represent the accurate present scenario of U.K. But the researcher tried to spotlight on the NHS which have the qualified and experience repetitiveness

I got some financial problem because the research was completed by self financing. And I had to spend a lot of money in phone calls, photocopy and some other related tasks.

5.3 Future Research

This research will be the great platform for the future researcher to get information. As mentioned before during the survey and analysis I had found a very sensitive issue that is related to one kind of racism. The nurses reported that they were abused by patients. Racism causes the moral dissatisfaction. This may be another set of factors that impact on retention. Some key questions for further research could be :

• To what extent does this exist?
• How does it impact on retention?
• How could it be tackled?

Also due to limitation of time it was not possible get the interview of nursing professional body. To find more factors that impact on nurse retention, get information from them also important.

Recommendations

1. Increase the relationship between service and education

NHS should increase the facilities for higher education for nurses. As much as possible Nurses demand for higher education must be encouraged. To providing education to practicing nursing hospitals, schools and other professional institute should be encouraged to provide facilities for on-site and on-line courses for nurses. Education Cost and financial sources are required to be focused cautiously. Also availability of external financial support should be recognized. NHS should include doctoral studies for nurses. Higher educational facilities should be designed in a way that nurses do not need to quit current nursing job in order to complete his/her courses or degrees. For the nurses who working, some masters degree programs are arrange the accommodation. Gradually, doctoral courses should provide same facility

2. Improvements in practise environment and working life

Improving working conditions, achieving supportive practice environments and providing for a sustainable work-life balance are key to improving nurse retention and long-term recruitment. A number of different strategies are required to achieve these objectives. To create a better working life environment NHS should take several steps. First of all they can introduce social and recreational programs. Social programs may include Christmas parties , tea and dinner parties. Recreation program like fitness program can be arranged on-site or off site. Secondly NHS should provide family care facility that will create employees loyalty to NHS and retain skill nurses for long time. Thirdly, job security is a most important factor for nurse retention. NHS can provide a grievance procedure to increase worker security so that employees need not fear being terminated unjustly as a result of arbitrary managerial action. At last, NHS can develop employee assistance program to help their staff that will reduce the early termination of nursing profession.

3. Career Progression

Some of the most fundamental discouragements to nurse retention arise from career progression. NHS should focus on nurses Carrier Progression. NHS must provide enough facilities for promotion.

4. Pay

This is the section where NHS have to work more. From the analysis it can be found that nurses were dissatisfied because of NHS payment scale in compare to their responsibility and work pressure. Though they also mentioned working condition and management are the major factor for dissatisfaction but pay compensate for the discomforts of work. And in recent years these discomforts have tented to increase at a more rapid rate than pay. Nurses should get competitive salary.

5. Work value

Valuation of work is another factor of nurse retention which is needed to be focused. Analysis of survey found that nurses are not valued. NHS should design a plan for staff assessment. They can also develop reward arrangement for appreciate the good works of nurses.

6. Management

Nurse management should be efficient to retain nurses. Managers should behave friendly and helpful with staff. They should always encourage the new nurses and support them through proper training. Managers also look after the working conditions. They should ensure that staffs are not being abused by patients. Managers can talk to the nurses in case of decision making to make a healthy and good working environment. If the nurses are involved in decision making then they will be motivated to stay in NHS.

7. Developing pension and benefits policies

Nurses who move between positions during the course of their career often face loss of full pension benefits; those who move to part-time or per diem positions may face loss of health insurance and other benefits. This is true even for nurses who make a career-long commitment to the profession but who change employers (and/or hours). Pension and benefits portability are available within government hospital or health systems and some private systems.

References

Books

Alexander, Z. and Dewjee, A. (1984). Wonderful adventures of Mrs. Seacole in many lands. : Falling Wall Press, Bristol.

Baly, M. E. (1980). Nursing and social change. (2nd edn) Bath: Pitman Press. Pp-373

Beishon, S., Virdee, S. and Hagell, A. (1995). Nursing in multu-ethnic NHS. London: PSI. pp.225-236

Bowin, R.B. (1987). Human Resource problem Solving. Engelwood Cliff. Prentice Hall

Bryman, A. and Bell, E. (2003) Business Research Methods, Oxford University Press, Oxford.

Collis, J. and Hussey, R. (2009) Business Research (3rd edition), Palgrave Macmillan, UK, pp.154-197.

Davies, C. (1995). Gender and the professional predicament in nursing. Open University Press. Buckingham.

Dell, D. and Hickey, J. (2002) Attracting and keeping top employees, Conference Board, New York.

Famularo, J.J. (1986). Handbook of human resources administration, Second Edition, McGraw-Hill, New York,

Fitz-enz, J. (2000), The ROI of Human Capital. New York: Amacom publishing.

Glaster, B. and Stauss, A. (1967) The Discovery of Grounded Theory, Chicago, IL, Aldine.

Glueck, W.F. (1978). A Diagnostic Approach, Revised Edition, Business Publications, Dallas, TX.

Huston, C. Marquis, J. and Bessie.L. (1989) Retention and Productivity: strategy for nurse managers, Lippincott Company, pp 349-380

Levering, R. and Moskowitz, M. (1993), The 100 Best Companies to Work for in America. Bantam DoubleDay Publishing Group, New York:

Mobley, W.H, (1982) Employee Turnover: Causes, Consequences, and control. Reading, MA: Addison-Wiseley Publishing Company,

Moos, R. H. (1994),Work environment scale manual: A social climate scale: Development, applications, research(3rd Ed.).Consulting Psychologists Press. (Original work published 1981), Palo Alto, CA:

Peters, T. and Waterman, R. H. (1982) In search of Excellence. Harper and Row, New York.

Phillips J. J. and Connell, A.O. (2003). Managing employee retention: A strategic Accountability Approach, Pub: ELSEVIER Butterworth Heinemann, USA.

Robson, C. (2002) Real World Research, Second Edition, Oxford, Blackwell, pp.58-178

Smith, M., Thorpe, R., and Lowe, A. (1993) Management Research: an Introduction, Sage Publications, London, p.73

Saunders, M., Lewis, Thornhill A, (2003) Research method for business students, third edition, Pearson education Ltd, England, pp. 91-409

Saunders, M. Lewis, P. and Thornhill, A. (2007). Research method for business students (4th edition), Prentice Hall, Pearson Education.Limited, England, p132-133.

Silverman, D. (2006) Interpreting Qualitative Data, Third Edition, Sage Publications Ltd, London.

Strauss, G. and Sayles, L.R., Personnel (1972): The Human Problem of Management. Third Edition, Prentice-Hill, Englewood Cliffs, NJ.

Journals, Articles and Government Publications

Aiken, L., Clarke, S., Sloane, S., Sochalski, J., and Siber, J. (2002). Hospital nurse staffing and patient mortality, nurse burn out and job dissatisfaction. Journal of the American Medical Association, 288:16, 1987-93

Audit Commission (1997a). Finders, Keepeers: The management of staff turnover in NHS Trusts. London: Audit Commission

Bergstrom, W.S. (1988). “Fitness programs move to plant floors”. Sacramento Bee, 12 June, p.E2.

Boyle, D.K., Bott, M.J., Hansen, H.E., Woods, C.Q., and Taunton, R.L. (1999). Managers' leadership and critical care nurses' intent to stay. American Journal of Critical Care, 8: 361-371.

Bratt, M.M., Broome, M., Kelber, S. and Lostocco, L. (2000). Influence of stress and nursing leadership on job satisfaction of pediatric intensive care unit nurses. American Journal of Critical Care, 9: 307-317

Buchan, J., Seccombe, I., and Smith, G. (1998). Nurses’ work: an analysis of the UK. nursing labour market. Ashgate Press. Aldershot.

Bush, J.P. (1988), Job satisfaction, Powerlessness and locus of control, Western Journal of Nursing Reseaerch, 10, pp.718-731

Butler, j and parsons, R. (1989). Hospital Perceptions of job satisfaction, Nursing Management, Vol.20, No.8, pp.45-48

Buchan, J. (2000). Nursing Workforce Data.A Special Report 1999-2000. Chamberlain Dunn Associates Ltd.

Cameron, A. and Masterson, A. (2003). Reconfiguring the clinical workforce. In Davies C (Ed).The future health care workforce. Palgrave MacMillan, Basingstoke

Clark, A. E., Oswald, A. J. and Warr, P. (1996), Is Job Satisfaction U-shaped in Age? Journal of Occupational and Organizational Psychology, 69: 57-81.

Clark, A. E. and Oswald, A. J. (1996), Satisfaction and Comparison Income. Journal of Public Economics, 61:359-382.

Clark, A. E. (1997). Job Satisfaction and Gender: Why are women so Happy at Work? Labour Economics, 4: 341-372.

Coomber, B., and Barriball, L. (2007). Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature. International Journal of Nursing Studies, 44: 2, 297-314

Davidson, H., Folcarelli, P.H., Crawford, S., Duprat, L.J. and Clifford, J.C. (1997).The effects of health care reforms on job satisfaction and voluntary turnover among hospital-based nurses.Medical Care, 35:634-645

Davey, B., Murrells, T. and Robinson, S. (2005). Returning to work after maternity leave: UK nurses’ motivations and preferences. Work, employment and Society, 19:2, 327-348

Davies, C. and Rosser, J. (1986). Processes of discrimination; a report on a study of woman working in the NHS. Department of Health and Social Security, London

Department of Health (1997).The new NHS: modern and dependable. Department of Health, London

Department of Health (1998).A first class service: quality in the new NHS. London. HMSO.

Department of Health (1999) Making a Difference: strengthening the nursing, midwifery and health visiting contribution to health and health care. London: Department of Health.

Department of Health (2000a).The vital connection: an equalities framework for the NHS. Department of Health, London

Department of Health (2000b).The NHS Plan: a plan for investment, a plan for reform. The Stationery Office, London

Department of Health (2004).Agenda for change: final agreement. Department of Health, London

Department of Health (2005). HR in the NHS Plan, Department of Health, London

Department of Health (2006). Modernising nursing careers, setting the direction.

Department of Health, London

Donner G, and Wheeler M (2001) Career planning and development for nurses; the time has come. International Nursing Review, 48: 79-85

Fletcher, J. (1997). Do nurses really care? Some unwelcome findings from recent research and inquiry. Journal of Nursing Management, 5: 45-50

Freeman, R. B., (1978). Job Satisfaction as an Economic Variable. American Economic Review, 68:135-141.

Garrett, D.K. and McDaniel, A.M. (2001). A new look at nurse burnout: The effects of environmental uncertainty and social climate.Journal of Nursing Administration, 31:91-96.

Hakesley-Brown R (1999). Different routes to professional nursing. Nursing Times, 95:50, 51-52

Hakim, C. (2000). Work-Lifestyle choices in the 21st century-preference theory. Oxford University Press, Oxford

Hayward, J. (1992). Of graduates and Kings. RCN monograph. Royal College of Nursing, London

Hutt, R. and Buchan, J. (2005). Trends in London’s NHS workforce: an updated analysis of key data. The King’s Fund, London

Jeskins, R. L. and Henderson, R. L. (1984).Motivating the staff: what nurses expect from their supervisors. Nursing Managemen, Vol.15, No. 2, pp 13-14

Jonas Centre for Nursing Excellence. (2006). Workforce Diversity: Two Key Issues in New York City’ s Nursing Crisis, pp.7-10.

Korman, A. K., Glickman, A. S. and Frey, R. L. (1981). More is not better: two failures of incentive theory: Journal of Applied Psychology. Vol. 66, pp. 255-259.

Kramer, M. and Schmalenberg, C.E. (2005). Best quality patient care: A historical perspective on Magnet Hospitals. Nursing Administration Quarterly, 29:3, 275-287.

Lader, D. (1995). Qualified Nurses, Midwives and Health Visitors. HMSO, London.

Letvak, S. (2002). Retaining the older nurse. Journal of Nursing Administration, 32: 387-392.

Martin, J. and Roberts, C. (1984).Women and employment: a lifetime perspective. HMSO, London

Maylor, U., Newman, K., Chansarkar, B. and Leigh, S. (2000). Nurse Retention in London 4 Hospitals, London: Middlesex University, pp.28-30

McVicar, A. (2003). Workplace stress in nursing: a literature review. Journal of Advanced Nursing, 44:6, 633-642

National Health Service Executive (2002). Human resources in the NHS Plan. Department of Health, London

Newman, K. and Maylor, U. (2000). Nurse Retention In the London Region. Middlesex University, London, pp.20-28

Nolan, M., Lundh, U. and Brown, J. (1999). Changing aspects of nurses’ work environment: a comparison of perceptions in two hospitals in Sweden and the UK and implications for recruitment and retention of staff. NTResearch, 4:3, 221-233

Payne, D. (1994). A degree of improvement? Nursing Times, 90:24, 18

Robinson, S., Murrells, T. and Cox, S. (2003a). Adult branch diplomates: the first six months. Nursing Research Unit, King’s College, London

Robinson, S., Davey, B. and Murrells, T. (2003b). Family-friendly policies: general nurses’ preferences and experiences. Journal of Health Organization and Management, 17:6,422-437

Robinson, S. and Bennett, J. (2007). Career choices and constraints: influences on direction and retention in nursing, King’s College London.

Rosenstein, A.H. (2002). Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 102:6, 26-34.

Royal College of Nursing (2000).Making up the difference: A review of the UK nursing labour market in 2000. London: RCN.

Robinson, S. and Bennett, J. (2007). Career choices and constraints: influences on direction and retention in nursing, King’s College London.

Rosenstein, A.H. (2002). Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 102:6, 26-34.

Royal College of Nursing (2000).Making up the difference: A review of the UK nursing labour market in 2000. London: RCN.

Royal College of Nursing (1995). A principled approach to nurse education. Royal College of Nursing, London

Sausmann, C. (2003).The future health workforce: an overview of trends. In: Davies C (ed) The future health care workforce. Palgrave MacMillan, Basingstoke

Seccombe, I. and Smith, G. (1997). Taking Part: Registered Nurses and the Labour Market in 1997. The Institute for Employment Studies, Brighton.

Seccombe, I., Ball, J. and Patch, A. (1993).The price of commitment: Nurses’ pay, carrer and prospects, Institute of manpower studies, Report No. 251.

Seccombe, I., Patch, A. and Stock, J. (1994). Workloads, pay and morale of qualified nurses, Report-272, pp. 5-16.

Shields, M. and Ward, M. (2001).Improving nurse retention in the National Health Service in England: the impact of job satisfaction on intentions to quit. Journal of Health Economics, 20: 677-701

Sloane, P. J. and Williams, H. (1996) Are “Overpaid” Workers really unhappy? A Test of the Theory of Cognitive Dissonance. Labour, 10:3-15.

Smith, G. and Seccombe, I. (1998). Changing times: a survey of registered nurses in Brighton. Institute for Employment Studies.

Suggett, S. (2003), Recruitment And Retention Strategy ,Wandsworth Primary care trust(NHS),Uk

Taunton, R., Boyle, L., Woods, C.Q., Hansen, H.E. and Bott, M.J. (1997). Manager leadership and retention of hospital staff nurses.Western Journal of Nursing Research, 19:205-222.

United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1987). Project 2000 the final proposals. Project Paper 9. UKCC, London

United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1999). Fitness for practice: The UKCC commission for nursing and midwifery education. UKCC, London

Waters, J. (1997). Childcare: the missing link. Nursing Times, 93:41, 14-15

Willis, J. (1991). Equal to the task. Nursing Time, 87:31, 29-30

Internet sources

Audit Commission (1997b), Career focus, Availavle at http:// www.bmj.com/cgi/content /full/314 /7081/S3a-7081[Accessed 2nd February.2009]

Finlayson, B., Dixon, J., Meadows, S. and Blair, G. (2002). Mind the gap: the policy response to the NHS nursing shortage. BMJ.Vol.325, pp.24-42.Available at http://www. bmj.com/cgi/content/full/325/7363/541?ijKey=c2dea5997d85377dbe8dbd802141f5158adad4de&keytype2=tf_ipsecsha#B12 [Accessed 21st July. 2009]

Lewis, S. J., Gage, H. M., Pope, R., Lake, F., Pinder, M. J. and Beggs, F. D. (2002). Retaining Nurses In the NHS, BMJ, 325. Available at http://www.bmj.com/cgi/content/ extract/325/7363/538 [Accessed 8th July.2009].

Nursing Times (2009). Why flexible working is an active career choice within the NHS. Available at http:// www.nursingtimes.net/nursing-times-this-weeks-issue/ nhsProfess ionals/why-flexible-working-is-an-active-career-choice-within-thenhs/5001764.article [Accessed 7th July. 2009].

Appendices

Interviews

Interview-1

1. Why nurses are leaving NHS?

I think because of dissatisfaction on payment. Then work pressure for overtime

Do you train the nurse?

Actually we train the new nurses when they start their job

Do you think that you have shortage of skill nurses at this moment?

Yes at this moment we have shortage of nurses.

How do you run your department with shortage of staff?

Other nurses are doing overtime.

Don’t you think that long hour working creates work stress?

Yah sometimes long shift working creates work stress.

Do you support any rewarding system to childcare facilities motivate nurses ?

Yes, I support strongly to rewarding the Nurse for their good job. But here nobody practise it. I support but at the moment we don’t provide that facility. May be in the future we will do it.

Do you think that nurse payment is low in compare to other profession and their responsibilities?

Nurses leaving NHS because low payment. I think Payment should be increased to retain them.

What steps NHS should take to retain their skill nurses?

First of all increase in payment then give them their preferable shift, recruit more nurses and proper training facility also.

Do you think that NHS should go for graduate workforce?

Yes, I think NHS should try it. At the moment most of the nurses have only Diploma.

Do you allow nurses to work in flexible shifts?

We do but sometimes its not possible to give flexible hours. We don’t have enough staff.

Do you have enough facility for career progression of Nurses like promotion?

Yes, there is plenty of opportunity for nurses to rise up their rank.

Are the nurses abused in work place?

They are not abused by colleagues or any staff working here but sometimes they are abused by patients

Interview-2

1. Why nurses are leaving NHS?

less payment compare to responsibility and also working stress. Sometimes they are getting better salary than here.

2. Do you arrange proper training for the nurses?

Other said training is very important for nurses And we have enough facilities for training. Moreover if some one need training we can arrange training for him.

3. Do you think that you have shortage of skill nurses at this moment?

Yah we have some shortage of some skilled nurses.

How do you run your department with shortage of staff?

It is difficult say but we manage it. Sometimes we call the nurses from agency or sometimes our own staff doing overtime.

Don’t you think that long hour working creates work stress?

May be because they had to work hard all day.

Do you support rewarding system childcare facilities to motivate nurses?

I always appreciate if someone is doing good job. Rewarding may be good way to motivate. Childcare facility is very important for female nurses. But unfortunately we don’t have that facility.

Do you think that nurse payment is low in compare to other profession and their responsibilities?

I think compare to working responsibility payment is good enough

What steps NHS should take to retain their skill nurses?

I think reducing the work pressure by recruiting more people and increase the payment.

Do you think that NHS should recruit graduate Nurses?

NHS can recruit graduate. Graduates have more knowledge of nursing than diploma holder..

Do you allow nurses to work in flexible shifts?

It depends. sometime it possible or sometime not. It depends on the available flexible shift.

Do you have enough facility for career progression of Nurses like promotion?

They have the opportunity to be a senior nursing manager.

Are the nurses abused in work place?

Sometimes they are abused by patients.

Survey Questionnaire and result

Q What are the motivations to keep you in nursing job?

relationship with manager