Study identifies key factors influencing NHS hospital staff retention

BMJApr 18 2024

Age-related and contractual factors seem to be stronger drivers of NHS hospital clinical staff retention than organizational factors, suggests research published in the open access journal BMJ Open.

Efforts to keep staff in post need to be tailored to age and profession, rather than applying a 'one-size fits all' approach, the findings indicate.

And much better reward systems are needed to boost staff retention and ensure the sustainability of the NHS amid increasing demand for healthcare and an aging workforce, conclude the researchers.

To explore the range of factors informing healthcare professionals' desire to stay in post, the researchers looked at the demographic, contractual, and organizational factors, such as staff engagement and job satisfaction, associated with the retention of clinical staff working in acute and mental health care in NHS hospital trusts in England.

They included a total of 70,777 senior doctors, aged 30 to 70, and 448,568 nurses and midwives of all grades, aged 20 to 70, working in NHS hospitals in 2009-13 and in 2014-18. They drew on staff survey responses and employment records to track their retention up until 2019-20.

Nearly a quarter (23%) of senior doctors in acute care hospitals held a part-time position, rising to almost a third (32%) in mental health trusts. The opposite held for nurses, with 38%-41% of those working in acute care and 27%-29% of those working in mental health holding a part-time post across both groups.

Around 9% of doctors were employed under a fixed term contract, while 3% were in temporary locum posts. But only 2% of nurses and midwives were in fixed term posts.

Only around half of all clinical staff in the 2009 group were still working at the same trust 5 years later. This trend was especially noticeable among nursing staff.

In mental health trusts only 42% of nurses from the 2014 group worked in the same organisation for 5 years, compared with 54% in the 2009 group.

Senior doctors from ethnic minority backgrounds working in acute care were less likely to stay at the same trust than White senior doctors. Senior doctors from Europe or other parts of the world were also less likely to be retained within the same trust in both timeline groups.

Female nurses were more likely to stay at the same trust than male nurses. But in mental health trusts, the odds of female nurses and midwives staying in the same organization fell sharply in the 2014 timeline group compared with the 2009 timeline group, both after 1 and 5 years.

Nurses of Asian ethnicity from the 2009 timeline group were almost 75% more likely to stay at the same hospital trust for five years than White nurses. But black nurses in the 2014 timeline group were less likely to remain at the same Trust, both after 1 and 5 years.

International nurses from both timelines, on the other hand, were more likely to stay in the same trust, but only if they worked in acute care.

Part-time work was positively associated with nurse retention in both mental health and acute care, while working on a fixed term contract decreased the odds of staying at the same trust for longer periods.

The retention rate of senior doctors and nurses fell after the age of 50, both in terms of moving to other hospitals and leaving the NHS altogether.

In terms of potentially influential organizational factors, a higher engagement score on the NHS survey was strongly associated with the retention of nursing staff under the age of 51 in both acute and mental health hospitals, and with the retention of senior doctors in this age group working in acute care.

Trust line managers who acted on staff feedback was the only other organizational factor strongly associated with retention after 1 year, but only for older nurses and midwives in acute care hospitals. 

No other organizational factors emerged as significant other than understaffing in mental health hospitals which was strongly associated with younger doctors leaving their posts.

This is an observational study, and as such, no firm conclusions can be drawn about causal factors, added to which the data don't capture recent potentially highly influential events, including Brexit, the COVID-19 pandemic, and recent industrial action, acknowledge the researchers.

 Similarly, other factors, such as Care Quality Commission (CQC) ratings and local housing costs weren't included in the mix, but might also influence retention, they add. 

"The study's results reveal heterogeneous drivers of retention between occupations and care settings," write the researchers, adding that the findings "underscore the importance of disaggregating retention challenges and solutions both by occupation and specialization rather than taking a one-size-fits-all approach."

Part time work, for example, seems to work well for nurses, possibly because it's more flexible and suits those with care duties, but not for doctors, possibly because they consider it precarious and unfulfilling, they suggest.

"Retention is lowest for younger and older staff, who are more mobile. Younger staff have lower opportunity costs to change jobs. Older staff retention is linked to retirement, as those who were 51+ have the highest rates of leaving the NHS," they write. 

They note: "The NHS faces great challenges in retaining valuable staff amidst high turnover, aging demographics and growing care demands. With doctor trainee retention rates plummeting over the past decade and over half of consultants anticipating early retirement, this analysis sounds the alarm on unsustainable workforce dynamics that may jeopardize NHS future functioning."

And they conclude: "Demographic and contractual factors appear to be stronger predictors of hospital staff retention than organizational characteristics. The poor retention observed reinforces calls for healthcare organizations to develop more effective reward systems aimed at increasing staff retention."