Analysis

The high turnover of chief nurses and why it undermines front-line staff

Many directors of nursing don’t get a chance to hit their stride – or champion their staff

Many UK directors of nursing don’t get a chance to hit their stride – or champion their staff

  • With the turnover rate remaining at over 50%, financial pressures and staff shortages as cited as contributing factors
  • Experts fear that front-line staff experience a lack of consistency and coherence
  • How to become a successful nurse leader and engage nursing staff
Illustration highlighting the 'conveyor belt' of nurse directors due to high turnover in the NHS
Picture: Dan Mitchell

The high turnover of chief nurses in NHS organisations may translate into a lack of stable leadership and inadequate support for front-line staff, nursing experts warn.

Figures analysed by Nursing Standard show that half of all UK directors of nursing have been in post for two years or less.

Among the 248 NHS organisations in the UK that we surveyed, 51% (126) have permanent or interim chief nurses who took up their post in or after October 2017.

Signs of ‘deeper organisational malaise’

High turnover at senior level in NHS nursing could contribute to a lack of consistency and coherence in how front-line nurses are being supported in some organisations, argues nursing workforce expert Jim Buchan.

219

of the UK’s nurse directors are women, the remaining 29 are men 

Source: Nursing Standard

‘Some turnover at senior level is necessary and positive, where it means job moves and career promotion,’ says Professor Buchan, who is based in the health and sciences faculty at Queen Margaret University, Edinburgh.

‘But a constantly high level might be a symptom of a deeper organisational malaise.’ 

The figures are almost unchanged from last year, when a Nursing Standard analysis revealed that 52% of chief nurses (128) at organisations surveyed across the UK had taken up their post within in the previous two years, suggesting turnover was high.

‘Directors of nursing want to deliver meaningful change, but are often left without the means to do it. It is unsurprising that some are frustrated’

Bronagh Scott, RCN director of nursing, policy and practice

RCN director of nursing, policy and practice Bronagh Scott says high turnover is ‘a serious concern’ related to a combination of factors.

Struggling with demand and financial pressures 

'The director of nursing provides strong, professional leadership to the nursing workforce and is crucial in ensuring the profession is seen, heard and able to influence,' she says.

Bronagh Scott, RCN director of nursing, policy and practice
Bronagh Scott: ‘High turnover undoubtedly
affects the stability of the nursing workforce’

‘[High turnover] undoubtedly affects the stability of the nursing workforce throughout an organisation.’

Ms Scott suggests that ‘years of a health service struggling to meet demand, sustained financial pressures, and chronic nursing workforce shortages’ have left many nursing leaders ‘feeling like they have their hands tied behind their backs’.

She adds: ‘Directors of nursing are asked, and want, to deliver meaningful change, but are often left without the means to do it. It is unsurprising that some are left feeling frustrated.’

Staff have to adjust to different leadership styles

Directors of nursing who spoke to Nursing Standard emphasised the importance in this role of engaging with front-line nurses.

Croydon Health Service NHS Trust chief nurse Elaine Clancy says ‘people like to know where they are’. Too much change, such as that brought about through rapid turnover of directors, can have a detrimental effect, she says.Infographic showing the breakdown of director of nursing turnover by country

‘Different leaders have different styles, approaches and priorities, and that can unsettle people.’

Ms Clancy took up her post in May, in a new joint role in which she is also chief nurse for NHS Croydon Clinical Commissioning Group.

The former emergency nurse was previously deputy chief operating officer at Croydon Health Service NHS Trust and has worked for most of her 30-year career in the London borough.

An open invitation for all nurses to meet the senior nursing team

Ms Clancy says it is ‘incredibly important to be visible’ as a leader to understand nurses’ issues and represent the nursing workforce through strategic decisions.

To this end, she spends a lot of time talking to nurses on the wards and in units, trying to build up relationships.

‘I am a nurse through and through – nursing is who and what I am – and I need to be talking to teams and seeing the issues. Staff won’t talk to you if they don’t see you and you don’t talk to them.’

A number of Croydon Health Service NHS Trust’s initiatives also work towards this goal. 

Every Friday, the trust runs Croydon Cares, an open invitation for all nurses to meet the senior nursing team, as well as listen to talks on various aspects of the organisation’s work. 

Ms Clancy, along with other members of the trust's executive team, is also involved with the First Responders’ weekly scheme, in which senior managers take a trolley with refreshments around and stop to chat with staff. She says feedback from staff has been incredibly positive.

‘After five years, I’m seeing the benefits’ 

West Hertfordshire Hospitals NHS Trust chief nurse Tracey Carter has been in post since 2014.

Tracey Carter, chief nurse at West Hertfordshire Hospitals NHS Trust
Tracey Carter: ‘I couldn’t have done what
I’ve done without the work of my colleagues’

In 2015, the trust had a 32% vacancy rate of whole-time-equivalent band 5 adult nurses and was spending £37 million a year on agency nurses. 

Fast-forward to October 2019, and the trust has filled all of its 733 whole-time-equivalent band five adult nurse vacancies.

Ms Carter credits her length of time in post and the continuity it gives to the trust as one of the crucial factors in improving recruitment and retention.

The impact of continuity on recruitment and retention

‘It is five years down the line [from taking on the role] that I’m starting to see the benefits,’ she says.

The trust has improved ties with local universities to attract nursing students, and Ms Carter says she makes it her business to meet students on placement, describing them as the future of nursing.

Things have also improved for the existing workforce, with nurses across all bands able to attend career workshops offering insight into career development.

However, Ms Carter says these changes were made with support from colleagues. ‘No man is an island,’ she says. ‘I couldn’t have done what I’ve done without the collective work of my colleagues.’

 

‘Engaged’ NHS directors are curious about staff experiences

nurse directors in England (3.5%) are BME, despite 21.3% of all nurses and health visitors being from BME backgrounds 

Source: Workforce Race Equality Standard

Claire Johnston spent 15 years as the director of nursing and people at Camden and Islington NHS Foundation Trust, leaving in Decemver 2017.

She is now programme lead in north London for the Capital Nurse programme, which works to ensure London has the right number of nurses through collaboration between HR and nursing directors, Health Education England, NHS England, NHS Improvement and trade unions.

Ms Johnston says that in her own geographical area, she sees ‘engaged’ directors of nursing and primary care leaders who are ‘constantly curious’ about what their nurses are experiencing, thinking or aspiring to do for better and safer care.

‘It unlikely there is a director of nursing now in any health and care organisation, independent or NHS trust, little or large, who is not spending at least 20% of their week with operational nurses in clinical settings,’ Ms Johnston says. 

‘And they will all – as the chief nurses are in our ten trusts in north central London – be on Twitter, sharing weekly blogs and setting up chat rooms to reach out and listen.

‘If any are misunderstanding the purpose of their role or have behavioural traits which inhibit that essential passion for nursing and being able to represent their nursing workforce which the role demands, they need to be counselled out.’

How to be a successful nurse leader 

Claire Johnston, former director of nursing and now programme lead for the Capital Nurse programme in north London
Claire Johnston: ‘These jobs can be lonely’

Claire Johnston, formerly director of nursing and people at Camden and Islington NHS Foundation Trust for more than 15 years, says leadership roles are ‘not for the faint-hearted’. 

Here are her tips for new or aspiring directors of nursing:

  • Find a coach to work with Try a friendly neighbouring director of nursing from another trust. It might lead to great joint nursing programmes 
  • Focus on the right things Remember that leaders do not often win popularity stakes
  • ‘Well begun is half done’ So said Aristotle, and that's a maxim for me to seize the day and get going
  • Remember why you became a nurse What it meant to you then and now
  • Accept you will not always get it right No leader can in whatever sphere, including our politicians. But tomorrow is another wonderful day to try to succeed 

Ms Johnston says networking is critical to be effective as a leader. ‘The nursing leader community is amazingly friendly and open – and we know we need one another,’ she says.

'These jobs can be lonely and sharing with those who understand the game you are in, because they are too, matters.’

 

Sharper focus on retention at senior level

7.2%

of nurse director posts (18) are held on an interim basis

Source: Nursing Standard

With some nurse directors facing an uphill battle to realise their role profile in the current climate, the RCN’s Ms Scott has a message for NHS strategic and professional leaders.

‘We are calling on NHS England and NHS Improvement to place a much sharper focus on retaining these highly skilled directors of nursing,' she says.

‘It is so important that nursing leaders are supported to deliver on their vision for the nursing workforce and health and care in their organisation.'

NHS England chief nurse Ruth May has long been a vocal advocate of the need to support nursing leaders and has been involved in stabilising development programmes to nurture professional leadership.

Since 2016, NHS Improvement has led the Aspiring Nurse Directors Programme, which worked to identify and support the next generation of nursing leaders. By last year, Dr May said two thirds of participants had gone on to become directors of nursing.

At the time, she said: ‘This programme provides best practice, peer support, mentoring and an appropriate level of challenge to ensure that nursing leaders are equipped to navigate the challenges and complexities of a first-time board position.

‘Once in post we ensure there is a robust programme of regional support for every first-time director of nursing, as well as plenty of continued opportunities for peer learning and support.’

NHS England and NHS Improvement also run a wider Retention Programme, with trust-level initiatives including better utilising the expertise of experienced workforce and improving flexibility and career development.

An NHS spokesperson said: 'Directors of nursing play a vital role in the NHS as both organisational and professional leaders.

'To ensure consistency and provide support to nurse leaders, we are expanding our retention programmes to encourage senior nurses and midwives to stay within in the NHS for longer and to support the pipeline of leadership talent development.'

Additional reporting and data analysis by senior news reporter Kimberley Hackett


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