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Policy Research Programme - PRP (35-01-13) Understanding factors and motivations influencing late career NHS nurse retention

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Published: 10 January 2023

Version: 3.0 January 2023

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Timetable and Budget

DescriptionDeadline/Limit
Deadline for Stage 1 Applications 14 February 2023, 1 PM
Notification of outcome of Stage 1 Application April 2023
Deadline for Stage 2 application 06 June 2023, 1 PM
Notification of outcome of Stage 2 Application October-November 2023
Project Start Within 2 months of award notification
Project Duration 18 Months
Budget £350,000

Introduction

The National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP) invites applications for a single research project to investigate the motivations and factors influencing late career NHS nurses’ decisions to leave the NHS, and how the retention of these nurses might be improved.

The overall priority of this research is to understand what works to improve the retention of late career NHS nurses. It should consider the following questions:

    1. What factors are important when late career nurses make plans and decisions around leaving the NHS?

    2. To what extent do late career NHS nurses consider leave and return options (including, but not limited to, retire and return)? What factors influence their likelihood to consider returning after leaving, or delaying leaving?

    3. What encourages late career nurses to continue to work in the NHS, or work in some capacity after leaving/retiring (e.g. bank/agency alongside a permanent role, legacy mentoring roles [1])?

This evidence will support policy makers in the Department of Health and Social Care (DHSC) and Arms Lengths Bodies (ALBs) by providing evidence to inform decisions on policy interventions targeted at the nursing workforce.

Background

Retention of healthcare staff is a central, long-standing priority for DHSC and the Government. Improving retention of healthcare workforce in the NHS is vital to ensure growth in the NHS workforce alongside increased recruitment. It is also an important part of the programme to increase the number of registered nurses by 50,000 by the end of Parliament (N50k) and efforts to tackle the backlog in elective care.

The data shows that nurses are most likely to leave when they are in the early or late stages of their career. Work undertaken by the Institute for Fiscal Studies (IFS) shows that the probability of a nurse leaving the acute sector is highest in their first two years of tenure, decreasing steadily until they have served ~20 years before rising again [2, 3]. Data on leavers from NHS Digital [4] and the Nursing and Midwifery Council (NMC) register [5] show a similar pattern based on age, rather than length of service (nurses under 34 and over 55 make up the highest proportion of leavers).

Retirement decisions are of heightened relevance in workforce policymaking. The McCloud judgement has significantly altered retirement rationale for late career nurses, many of whom may now find they can retire earlier than expected for a given level of pension pay-out. There has been a recent increase in leaving from nurses approaching retirement age, possibly in part due to the cumulative impact of the pandemic on staff [4]. 

All NHS staff, regardless of age, should be able to have long and fulfilling careers. The retention of late career staff is, however, particularly important, because they bring vital experience and knowledge to the system, which is lost if they are not adequately retained. Furthermore, the NHS workforce is ageing (~half of staff are over 45), so while the service time gained by retaining a late career nurse is relatively short, the effect is magnified by large numbers.

The NHS and Government have already taken some steps to encourage late career nurses to extend their careers in the NHS. United Lincolnshire Hospitals Trusts published a report in August 2020, detailing successful targeted interventions to improve the retention of late career staff (including retire and return) [6] 

Previous studies [7] and ongoing research at Staffordshire University [8] have focused on long-standing factors that affect the retention of nurses generally (such as leadership, professional development, and stress), and their effects on patient outcomes. We anticipate that late career nurses, particularly those approaching retirement, are motivated by a different set of factors and concerns.   

Overall, therefore, the evidence base on how late career nurses specifically make decisions around leaving is very limited. A few studies have explored this subject for doctors [9, 10], but not for nurses. The current research is being commissioned to fill this gap, and to suggest ways in which the retention of this demographic might be improved. This is a perennial question in NHS workforce planning, and this research has potential to bring significant and long-lasting impacts to the NHS. 

We expect successful bidders to be aware of, and where possible to work in a complementary way and avoid overlaps with other ongoing relevant research. This may include retention research currently taking place within the 50,000 nurses evaluation programme.

Research priorities

While we encourage commissioned researchers to develop a suitable proposal to address our research questions, we have an initial view on appropriate methodology that bidders may consider in developing their proposals:

  1. Initial work to establish the current evidence base on late career nurse decision-making, potentially including:
  • Analysis of data from the Nursing and Midwifery Council (NMC) and NHS Electronic Staff Record (ESR), to create an in-depth profile of late career leavers/retirees, including nursing specialism, geography, and grade. DHSC analysts will support with data access.
  • Rapid literature review to establish what research evidence already exists on retention of late career staff. This could also include research on what has worked to encourage delayed retirement or retire and return in other UK public sector roles, or international comparisons.

     ii. Primary research to establish desire in the current workforce to continue working and/or delay leaving/retiring, including:

  • Survey of late career nurses to establish what % of staff intend to postpone/delay leaving/retirement, or to work additional hours/shifts in some form (e.g. bank) afterwards.
  • Qualitative fieldwork (interviews or focus groups) with late career nurses to discuss motivations, experiences, understanding, and plans around leaving/retirement, and what factors/issues they consider. Potential to also include recent leavers/retirees. 

     iii. Primary research to establish what, if anything, could incentivise late career nurses to stay, delay retirement, and/or leave then return in some capacity:

  • Discrete choice experiment with late career nurses to test different policy options/factors that could encourage them to stay longer or leave then return.

We envisage the secondary data analysis (part i) to be a smaller part of this research, with resources focused primarily on the discrete choice experiment (DCE)(iii). The sample for the DCE should be of sufficient size to enable detailed subgroup breakdowns (i.e. intersections of gender, region, ethnicity etc.)

Officials in DHSC will, as far as possible, enable access to relevant existing research and evaluation of constituent programmes and workstreams, and to relevant policy documents and similar. 

There is an important role for considering inequalities within this project. We would expect proposals to assess differential attitudes to late career decision-making by key demographics (such as region, gender, ethnicity, and nationality) and any relevant intersection between them. There are second order impacts and inequalities on patients that may result if NHS staff have differential attitudes to late career decision-making in a way that intersects with local socio-economic and demographic factors [8]. Bidders are invited to identify other areas where variation and inequalities will be relevant to this work. 

Research scope

This project is focused on registered nurses, with other staff groups (including midwives) to be outside its scope. Registered nurses are the largest NHS workforce group and are likely to be motivated by different factors and experiences than other staff groups. On balance, we would prefer to focus the project on the nursing workforce and intersections outlined under research priorities, with greater analytical depth and statistical power, rather than divide the project thinly across many staff groups. 

This project is focused on the retention of late career nurses within the NHS workforce; when considering leave and return options, we are specifically interested in those returning to contribute to the NHS (though information on where late career nurses go after the NHS, if not retiring, may be a relevant and useful finding).

Technical requirements / Expertise required

Suggested methods (as outlined above) include use of ESR and NMC administrative data, rapid literature review, surveying, qualitative fieldwork (interviews or focus groups), and discrete choice experiments.

We require the following expertise from the project team:

  1. Familiarity with the UK healthcare system, NHS workforce, and current organisational changes. Expertise in NHS workforce retention and/or NHS workforce policy.

  2. Labour economics, especially elasticity of labour supply, and comparison of NHS workforce supply trends to private and/or international comparators.

  3. Familiarity and expertise in working with and analysing administrative data such as the Electronic Staff Record and nurse registration data from Nursing and Midwifery Council.

  4. Designing, running, and analysing discrete choice experiments. Ideally expertise in drawing on qualitative research and other evidence to inform design of well-balanced choice options.

  5. Qualitative research - especially interviews and focus groups.

  6. Rapid literature reviews.

  7. Expertise in NHS workforce retention and/or NHS workforce policy.

  8. Experience of running mixed methods projects and track record in effective synthesising and communication of findings in such projects.

Outputs

Applicants are asked to consider the timing and nature of deliverables in their proposals. A meeting to discuss policy needs and timings with DHSC officials will be convened as a matter of priority following contracting.  

Expected outputs will include interim presentation(s), as well as a final report, and one or more slide packs.

Budget and duration 

Funds of up to £350k are available for this research. Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria that peer reviewers and commissioning committee members will assess applications against.

We estimate that this research will be completed within 18 months of contracting, though this timeline is relatively flexible. The need to increase the evidence base surrounding retention (and specifically late career nurse retention) is a long-standing one. We are keen to balance the pace of delivery while making sure this is a high-quality piece, which will provide a robust evidence base to inform future policy and interventions.

Management arrangements

A research advisory group including, but not limited to, representatives of DHSC, other stakeholders (incl. NHS England) and the successful applicants for the research should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. They will be expected to:

  1. Provide regular feedback on progress

  2. Produce timely reports to the advisory group

  3. Produce a final report for sign off

Research contractors will be expected to work with nominated officials in DHSC, its partners and the NIHR. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.

New Guidance on Health Inequalities data collection within NIHR PRP Research: 

New Guidance on Health Inequalities data collection within NIHR PRP Research:

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data, if appropriate for the research. Our goal is to collect information on health inequalities in research and data relating to the main outcome(s) of the proposed research. Please clearly identify in the research plan section whether or not your application has a health inequalities component or relevance to health inequalities and detail the core set of health inequalities breakdowns that will be reported; if none please explain why. We understand that research projects have different methodologies and focus on different populations, so please explain what data will be collected and reported for the methodology you plan to use. If a health inequalities component is not included, please explain why this does not fit within your proposed research. This should only be a few sentences.

For quantitative research we would ideally like researchers to provide one-way breakdowns of their main outcome(s) by the following equity-relevant variables: age, sex, gender, disability, region, 5 ONS Ethnic groups, and the 5 IMD quintile groups. If more detailed cross tabulations are appropriate, please include these. This table should be submitted to NIHR PRP at the end of the project. Due to data limitations, judgement calls may be necessary about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgement calls yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies.  More details and an example table can be found in Appendix A. 

For qualitative research projects, this can be purely descriptive statistics giving the number of observations against the various variables.

Further details about this new request can be found in Appendix A. 

A recording of the Health Inequalities in NIHR PRP Research Q&A Event which was held on 19 September 2022 is available to view on Youtube.

References and key documents

  1. Wilkinson-Brice E, May R. Retaining our nursing and midwifery colleagues. NHS England, 13 July 2022
  2. Kelly E, Stoye G, Warner M. Factors associated with staff retention in the NHS acute sector. Institute for Fiscal Studies, August 2022. 25-27
  3. Stockton, I. Nurses leaving the NHS acute and community sectors. Institute for Fiscal Studies, 23 June 2021. 
  4. NHS Digital. HCHS Nurses and health visitors turnover by age and ethnicity. 30 September 2022.
  5. Nursing & Midwifery Council. Breakdown by country of registered address (England data tables, 2021-22). 
  6. NHS Employers. Improving retention at all stages of nurses' careers: United Lincolnshire Hospitals NHS Trust. 11 August 2020
  7. Marufu T, Collins A, Vargas L, Gillespie L, Almghairbi D. Factors influencing retention among hospital nurses: systematic review. British Journal of Nursing. 2021 Mar 11;30(5):302-308.
  8. Jones S. NuRS and AmReS: nurse and ambulance workforce retention and safety, Staffordshire University
  9. Cleland J, Porteous T, Ejebu OZ, Ryan M, Skåtun D. Won't you stay just a little bit longer? A discrete choice experiment of UK doctors' preferences for delaying retirement. Health Policy. 2022 Jan;126(1):60-68.
  10. Cleland J, Porteous T, Ejebu OZ, Skåtun D. 'Should I stay or should I go now?': A qualitative study of why UK doctors retire. Med Educ. 2020 Sep;54(9):821-831. 

Appendix A: Further Detail on the New Guidance on Health Inequalities data collection within NIHR PRP Research

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data related to health inequalities, if appropriate for the research. Collecting specific information about health inequalities in research submitted to the programme will allow for categorisation of health inequalities research, curation of data to aid future health inequalities research and enable policymakers to better understand the implications of health inequalities within their policy areas. This is a new request from the NIHR PRP and we will be continuing to monitor queries and adapt the process as needed. If you have any feedback on this new request, please contact us at prp@nihr.ac.uk. 

Our goal is to facilitate more widespread and consistent reporting of health inequality breakdown data relating to the primary outcomes of NIHR funded research. We would ideally like researchers to focus on the following equity-relevant variables: age, sex, gender, disability, region*, 5 ONS Ethnic groups**, and the 5 IMD quintile groups. These variables are considered an ideal, but we understand that these are subject to change depending on the sample population and specific research question.  

For qualitative research projects, this can be purely baseline characteristics of the participants, for example, the number of participants in each ethnic group. 

For quantitative research projects, if there are multiple outcomes/effects with your stakeholders, select a small number of main outcomes as appropriate to report equity breakdowns. We will not be prescriptive about the number of the outcomes, as it will depend on the number of study design types and the nature of the project aims. We are asking for one way cross tabulations of each primary outcome by these equity-relevant variables, if appropriate for your research, together with the number of observations in each cell. If more detailed cross tabulations are appropriate for your proposed research, please include these as well. This request applies to both primary data collection studies and secondary analysis of routine data, and to causal inference studies as well as descriptive studies; however, if this is not possible due to data limitations then please explain. Due to sample size and other data limitations there may be difficult scientific and/or data security*** judgement calls to make about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgments yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. We also ask that researchers report breakdowns for the unadjusted as well as adjusted outcomes/effects, as appropriate.

We understand that research projects may employ different methodologies, and focus on different populations. Please explain how the variables and data collection methods chosen are appropriate to the methodologies used. 

We ask that you please clearly identify in the research plan section of the application whether your application has a health inequalities component or not and detail the core set of health inequality breakdown data that will be collected, if applicable. Submission of the data collection will be a condition of the final report for all research with relevant methodologies regardless of whether the research has a health inequalities component that will need to be submitted to NIHR PRP when the grant has finished. This should only take a few sentences within the research plan section. 

* Table below uses the nine regions in England, further regions can be used if using the UK as the study population. Please report region breakdown for large samples in nationally representative descriptive studies. There is no need to report this for small sample studies, for sub-national studies, or for quasi-experimental studies where it would require time-consuming re-estimation.

** White, Mixed/ Multiple ethnic groups, Asian/ Asian British, Black/ African/ Caribbean/ Black British, Other ethnic group. If the sample size is small then it is fine to report only some of the requested equity breakdowns and to merge some of the sub-groups as appropriate.

*** For guidance on how to handle data security concerns in reporting of sensitive data please see ONS guidance.

Example data table for submission at the end of the funded research project

(N.B. If there is more than one main outcome then you will require more tables and if you adjust your outcome then you will need two tables for the adjusted outcome and unadjusted outcome. For other methodologies, variable vs number of observations may be more appropriate to record participant data). This table is for an example only. It does not contain sub variables and does not illustrate any preference for certain variables, as these will be dependent on the proposed research.

VariableOutcome (an appropriate average for this subgroup, usually the mean)Number of observationsAdditional information about variation if appropriate, e.g. range, standard deviation
Age - - -
Sex - - -
Gender - - -
Disability - - -
Ethnic Group - - -
IMD Group - - -
Region - - -