Nurse retention: is your employer doing enough to keep you?
As staff quit the NHS in huge numbers, it’s more important than ever that nurses air their workplace worries, and employers listen and act on those concerns
- Nurse attrition is a long-standing challenge for the NHS, now given fresh focus as weary staff deal with fallout from the pandemic
- One nurse explains why struggling with work-life balance and team dynamics made her turn her back on her career
- Find out how an employer’s early warning mechanism alerts managers to factors that could force staff to leave if left unaddressed
More than 34,000 nurses left their jobs in the NHS in England in 2020-21.
Many of these were, of course, retiring – some having deferred doing so at the height of the pandemic. But staff retention is a chronic difficulty the health service can ill afford, as it grapples with safe staffing problems and high nurse vacancy rates.
Staff leaving due to burnout and exhaustion
It’s clear far too many nurses are turning their backs on what should be rewarding careers. Data analysis by Nursing Standard shows nurses are leaving their jobs in their thousands, as organisations fail to retain staff who are burnt-out, overworked and mentally and physically exhausted.
As the government and NHS England and NHS Improvement pledge to improve staff retention as part of the NHS People Promise, we ask whether enough is being done to give nurses a voice and address their reasons for resigning.
nurses left their jobs in the NHS in England during 2020-21
Work pressures are now beyond what nurses can cope with
‘What our members are telling us day in and day out is they are thinking of leaving partly because of the pressure of work,’ says RCN director for England Patricia Marquis.
‘There are a large number of vacancies wherever you work. If you are going into work and on a regular basis there are meant to be five of you on shift and instead there are two, the pressure goes far beyond what people can cope with.
‘In the past, this might have happened every fortnight, but now in many places it’s almost all of the time.’
‘Staff retention is more important than ever if we are going to close the holes in the leaky bucket of the NHS workforce’
Alison Leary, professor of healthcare and workforce modelling
Ms Marquis says working on understaffed wards often leaves nurses feeling guilty for not being able to deliver the level of care they want to.
‘They want to do more and they are going home after every single shift not having done what they needed to do. They feel guilty, and they feel guilty again when they get a text asking if anyone else can come in to cover a shift. It’s a vicious circle’ she adds.
‘People are leaving because of the pressure, and the people who remain are physically and emotionally exhausted.’
Nurse resignations from the NHS
Nursing Standard sent Freedom of Information request to all UK NHS trusts and boards to find out how many nursing staff resigned in 2021. Of those who responded, figures showed more than 25,000 NHS nurses left their jobs last year.
The largest number of resignations was seen at NHS Greater Glasgow and Clyde, the UK’s biggest NHS employer, where 1,308 nurses left their posts.
The figure for the same period at Manchester University NHS Foundation Trust was 989, with a further 579 at Belfast Health and Social Care Trust.
NHS Glasgow and Clyde and the Manchester trust attribute their relatively high numbers of departures to the sheer size of their workforces, along with a spike in deferred retirements during the pandemic.
A Glasgow and Clyde spokesperson says the organisation offers workforce well-being support that has been developed using staff feedback.
‘The NHS is being propped up on swathes of guilt. Nurses don’t want to let their team down or their patients down’
Jane Ball, professor of nursing workforce, Southampton University
University Hospitals Bristol and Weston NHS Foundation Trust saw 1,002 nursing staff leave in 2021, with 571 citing work-life balance as their reason. Of those, 302 were full time equivalent registered nurses.
According to NHS Digital, one in ten NHS nurses left the service in England in the year to September 2021. This proportion was even higher in the south west region, where one in eight nurses left their job in that period.
Why are nurses leaving the profession?
nurses left NHS Greater Glasgow and Clyde in 2020-21
Source: Freedom of Information request
Between April and September 2021, 13,945 nurses, midwives, and nursing associates left the Nursing and Midwifery Council register, compared with 11,020 during the same period in 2020. The 2021 figure represents a four-year high.
Data on why nurses leave the NHS are limited. Nurses are asked to complete an exit survey. NHS Digital data show that from April-September 2021, 21,875 nurses and health visitors gave their reasons for leaving their jobs; the most common were relocation (3,980), retirement (3,410), work-life balance (3,355), or promotion (2,175).
Other reasons included incompatible working relationships, childcare, lack of opportunities and health, although the categories are broad and it is unclear whether employers request further details.
‘Leaving made me feel sad because it was the place I wanted to build my career. But it had become too toxic to stay, and very emotionally draining’
Nurse who resigned from acute hospital role in 2021
According to London South Bank University professor of healthcare and workforce modelling Alison Leary, this dearth of information reflects a lack of effort to retain staff.
‘The fact that it is a tick-box exercise is intrinsic to the story. If the workforce is valued, then this would be investigated. There is a culture of high turnover, which is normalising indifference to the workforce and there isn’t a lot of talent management,’ Professor Leary tells Nursing Standard.
‘Staff retention is more important than ever if we are going to close the holes in the leaky bucket of the NHS workforce.’
Nurses are powered by guilt, and that’s unsustainable
Southampton University professor of nursing workforce Jane Ball agrees. She cites the most recent leavers survey by the Nursing and Midwifery Council (NMC), in which ‘too much pressure’ was cited by 22% of respondents as the reason for leaving, second only to retirement, while 18% blamed negative workplace culture.
‘This exit survey looks inadequate,’ she says. ‘They are not always filled in, and when they are we have no way of knowing what ‘other’ or ‘work-life balance’ means in reality.
‘People leave because their reason for becoming a nurse is no longer there. It’s easy to blame COVID-19, when we know a lot of these problems were here before, but the pandemic worsened things’
Simon Blake, chief executive of Mental Health First Aid England
‘Why is there no box for ‘over-worked’, ‘stressed’ or other reasons we know of for people leaving? It’s totally insufficient and gives us extremely limited insight into why people are going.
‘The NHS is being propped up on swathes of guilt. Nurses who don’t want to let their team down or their patients down, so they stay longer or go in for extra shifts, and it’s just not sustainable.’
Unrealistic rotas and other reasons I left my nursing career in the NHS
A nurse who resigned from her job at an acute hospital in 2021 tells Nursing Standard a change of manager and an unrealistic rota left staff burnt-out.
‘I mostly left because I was feeling completely burnt-out and wasn’t enjoying going to work every day as I used to,’ she says.
‘I was working in the ward I’d always wanted to, but it didn’t feel good anymore. I was frustrated not to be able to control my schedule due to the rota being so hectic and unrealistic and unhealthy.’
The nurse explains the sister who did the rota left the department, so that duty then passed to a manager.
‘Everyone felt the change. It was a mix of days and nights in the same week, not enough rest between shifts, which is a legal requirement.
‘Some dynamics in the team made me feel like I wasn’t welcomed anymore and pushed out. Leaving made me feel sad, because it was the place I wanted to build my career. But it had become too toxic to stay, and emotionally draining.’
What it would take to entice me back
To consider returning to her job, the nurse says she would need to feel like her voice was being heard.
‘The dynamic definitely changed since COVID hit the hospital and even though the patient care was impeccable, there was something different to before, something less based on the human side of care.
‘For me to stay, I would’ve needed mainly more voice. Staff were not listened to anymore and it is so obvious that everybody is getting burnt-out, but nothing is changing.
‘And to be completely honest a change of manager. I will not go back there with the same manager in place.’
Vacancies and staff sickness rates running high
Nurse numbers are declining across the board, in mental health nursing, community, children’s and district nursing in all parts of the UK.
Figures published on 3 March by NHS Digital show a vacancy rate of 10.3%, with 39,652 unfilled nursing posts in England. Along with a staff sickness rate around 7.5% for nurses, the pressure on current staff seems unsustainable.
nurses left Manchester University NHS Foundation Trust in 2020-21
Source: Freedom of Information request
Staff absence in England topped 94,000 on 10 January and has been running at more than 55,000 every day since the end of November 2021, when Omicron arrived in the UK.
In a submission to the NHS Pay Review Body sent in February, the Department of Health and Social Care said it was carrying out a significant programme to retain staff as part of the government’s promise to recruit 50,000 extra nurses to the workforce by the end of this parliament.
‘People need to feel valued at work and they need to see meaningful changes that make everyday differences to them’
Jane Ball, professor of nursing workforce
The submission states: ‘In addition to training and recruiting additional workforce and improving ways of working, there is a significant programme to retain and look after the existing workforce. Initiatives include improving staff well-being, fostering an increased sense of belonging, and promoting greater equality, diversity, and inclusion.’
However, when asked for more details on this programme, the department did not respond.
Current NHS pressures incompatible with nurses’ values and professional identity
Simon Blake, chief executive of social enterprise Mental Health First Aid England, explains that because of the nature of nursing itself, having less time to care for patients is detrimental to nurses’ sense of identity.
‘Nursing is about passion, compassion and care. Reducing someone’s ability to care because you are short-staffed, or because there is a huge demand on your service, affects nurses’ sense of job satisfaction and identity and their well-being,’ he says.
‘People leave because their reason for becoming a nurse is no longer there. It’s easy to blame COVID-19, when we know a lot of these problems were here before, but the pandemic has worsened things.
‘The sheer levels of trauma and pain that many nurses faced going to work during this time is very real. The trauma of having to use an iPad to allow families to say goodbye to loved ones should not be underestimated.’
What can be done to keep nurses?
In the past 14 years, Mental Health First Aid England has trained 4,000 mental health first aiders across 60 trusts to help support staff in the workplace.
But Mr Blake says without the time, space and continued access to these facilities, resources will go unused.
Big national issues such as pay and safe staffing clearly need to be addressed to retain nurses, according to the RCN’s Ms Marquis.
Getting the government in England to commit to a national workforce strategy is a key priority for the college. But when it comes to feeling valued day to day, small changes in the workplace can make a huge difference.
Parking spaces, having a locker that works, a staff room and time to have a break and eat a hot meal make staff feel valued.
How one trust is improving nurse retention
In 2017 Guy’s and St Thomas’s NHS Foundation Trust in London launched a retention strategy to cut ‘preventable resignations’, which they say has since stopped hundreds of skilled staff members leaving.
The trust saw that staff – especially nurses – were moving to other hospitals, and its own analysis revealed it could have prevented around 40% of departures by listening to nurses at an early stage.
Its strategy involves:
- ‘Stay discussions’ Rather than waiting until people resign to understand why they have left, the trust now encourages managers to have informal discussions after an employee’s first three, then first nine months
- Career navigation and progression The trust created a career development toolkit to help people consider career progression and prepare for interviews
- Internal transfer Ensuring that nurses can move easily from specialty to specialty in the trust. The trust created a nurses’ Facebook group, where job adverts are easily accessible
- Accommodation Expensive housing in London may mean staff decide to leave so they can live somewhere more affordable. Guy’s and St Thomas’s can offer some accommodation, and can offer loans to cover rental deposits
- Flexible hours The trust found that some managers were resistant to offering flexible hours, so it began working on how to make the organisation attractive and flexible, especially for staff with home or caring commitments
- ‘Leaver discussions’ When people do leave, the trust finds out their reasons for resigning and what could have been done to prevent them leaving. The trust has also introduced a mechanism to keep in touch with leavers to make it easier for them to come back in the future
Why NHS employers must seek to understand what is going wrong
Belfast Health and Social Care Trust says the loss of 579 of its nurses in 2021 is worrying. ‘We continue to work with our teams to identify ways to support nursing staff,’ a spokesperson says. ‘A range of measures are in place to help do this, including daily safety huddles, rest rooms for reflection and weekly staff engagement sessions supported by occupational health, psychology and trust human resources and trade union colleagues.’
But Professor Ball says that although some employers may be responsible for good practice, more needs to be done and quickly.
‘There has to be a circuit breaker,’ she says. ‘If the government is serious about getting 50,000 more nurses, and retaining the ones we do have as part of that strategy, we have to do more to understand what is going wrong.
‘People need to feel valued at work and they need to see meaningful changes that make everyday differences to them.’
- NHS People Promise
- NHS Digital: reasons staff leave, April-September 2021
- NMC registration data report
- NHS Digital: staff sickness July-September 2021
- Mental Health First Aid England
- NHS flexible working: how to apply and make it work you
- Nurse rosters: treating staff as individuals, not numbers
- How to hand in your notice without burning bridges
- Heading for retirement? Pension options and fulfilling opportunities to use your skills
- Want to quit? Here’s how the NHS is trying to change your mind