Improving the retention of registered nurses and midwives: A toolkit for line managers and employers

Introduction

The retention of registered nurses and midwives in all settings is critical to the delivery of high-quality services.

Registered nurses and midwives, as an integral part of the multi-disciplinary team, perform a varied range of essential roles to ensure safety and highest level of care.

Over the last decade, we have seen growth in the global and national demand for nurses and midwives. As the largest clinical workforce it is imperative that we do all we can to retain our highly skilled people.

There are a significant number of factors that influence retention. The aim of the nursing and midwifery retention self-assessment tool is to enable organisations to undertake a self-assessment against the seven elements of the People Promise plus key elements that support staff to deliver high quality care, enhance job satisfaction and support the retention of nurses and midwives.

The self-assessment tool has been developed by the national retention programme in the people directorate in collaboration with a range of key stakeholders including the nursing directorate, and in conjunction with nurses, midwives, human resources professionals and subject matter experts. It brings together a synthesis of evidence on factors which are influential in nursing and midwifery retention.

It is designed to be used as an appreciative enquiry tool and aims to help organisations to both identify and celebrate the successes they have achieved and to explore challenges. The tool is intended to be flexible to allow you to tailor it to your organisation. The dashboard tab provides a summary of results that can be used to support development of your retention improvement plans.

Additional resources have been developed to sit alongside the self-assessment tool, including a mapping document against the staff survey questions that could be used to support completion of the nursing and midwifery retention self-assessment tool.

About this toolkit

Getting started

There are several steps you can take to prepare for the self-assessment process. These will ensure that your assessment is objective, accurate and helps you develop a high-quality retention improvement plan as an output of the process.

It is just as important to learn from and celebrate what has been achieved and is working well, as it is to identify opportunities for improvement. The section below provides some broad principles for undertaking the self-assessment process for you to consider before you start.

Principles for conducting a self-assessment

Planning your self-assessment process

Having a clear and structured plan which outlines the steps you will take during the self-assessment process will help ensure you stay on track and are successful.

1. Nominate someone to lead the self-assessment process and its maintenance.
2. Ensure engagement and endorsement of senior leaders within your organisation as well as ensuring key stakeholders are included as appropriate. This includes registered nurses and midwives from across your organisation. You may want to consider information sessions/workshops before you start as well as using existing meeting structures.
3. Ensure you are including individuals across the organisation from board to ward and identify individuals to champion the self-assessment process in areas across the organisation to engage teams and support the process.
4. Take a strategic approach and set out your aims and expectations and be positive in identifying strengths and sharing achievements as well as focusing on areas for improvement.
5. Devise and agree an operational structure to support with the strategic approach for example, meetings and operation steering groups.
6. Work with your communications and engagement teams to keep people informed and share any successes or plans and their outcome.

Conducting your self-assessment process

These points will help ensure success when conducting your self-assessment:

1. Review the seven categories in the self-assessment tool. It may be helpful to start with the one that you feel most prepared for and have the data or evidence readily available.
2. Identify leads for each category. Where this includes more than one person, ensure there are regular feedback meetings for peer support and to share findings.
3. Engage champions in each area to work with the identified individuals and/or within their teams to discuss and gather evidence/examples to support the self-assessment process.
4. Consider how assessments can be objectively validated. This may include using the support of different teams to review self-assessments post completion.
5. Ensure the self-assessment tool is accessible to teams. This may include how they are accessed as well as in format.
6. Establish a central shared repository which complies with data protection requirements.
7. Identify how anecdotal evidence, feedback and stories will be captured.
8. Evaluate how you will evaluate the success of the process, including what has what worked well and what could be done differently.

Top tips

Prioritise

• It may be daunting looking at the self-assessment tool as a whole. Use the tips set out in the ‘conducting the self-assessment’ section to set your direction and priorities.

Ensure adequate time is given to complete the tool as capacity and time is limited

• Self-assessment can become a manual process as the information you require will not all be available at your fingertips. Try and avoid the self-assessment becoming a tick-box exercise – instead, consider how it aligns to and complements your organisation’s existing strategic priorities in terms of retention.

Determine how the tool is to be completed

• By ward, directorate, etc. Consider whether there will be a separate one completed for nursing and midwifery, as the results may be somewhat different.

You may want to consider using an online survey to gather views from departments for the narrative feedback.

Case study

• Ashford and St. Peter’s Hospital Trust identified key stakeholders and ran several staff workshops split by the People Promise themes to support their assessment process. Post self-assessment follow-up workshops were then organised to scope out the priority opportunities for areas where gaps had been identified. Using this information the team developed a driver diagram showing the key drivers and objectives behind the trust’s retention planning, which developed into a delivery plan with measures.

Using the self-assessment tool

It is important to use the tool in the context of your organisation and identify what good looks like for your circumstances. We know that every healthcare organisation will have a different context, so approaches will need to be tailored to meet the needs of your staff and organisation. Accumulating data across organisations can also be used for system-wide analysis when exploring collaborative work and joint investment in wellbeing across partner organisations.

By doing this, the tool will support you to:

• quickly understand your status against key areas affecting registered nursing and midwifery retention
• help you identify those areas for further improvement. This will help you to focus your efforts on areas will support nurses and midwives to stay and stay well in the NHS.

The retention self-assessment tool should be used together with this toolkit, which explains in detail why each element is important, what good looks like, helpful tips and tools, as well as providing guidance on developing your own retention improvement plan to help strengthen your overall retention strategy.

Complete the self-assessment tool

At the end of the self-assessment process, you should have a list of things to celebrate and build on, and a list of areas for further development via your retention improvement plan. This toolkit sets out more advice and best practice for each retention area in our dedicated guidance. Organisations are encouraged to use the information gathered in the dashboard to develop and implement their local evidence-based retention improvement plans.

It is recommended that the self-assessment process is reviewed every 6-12 months to track progress as part of this ongoing process.

Retention guidance

This section includes a helpful set of tips, tools and good practice examples from organisations across England to help you drive progress in retaining registered nurses and midwives. Leaders and line managers play a vital role in supporting and retaining our people.

We have suggested actions both leaders and managers can take to improve retention of nurses and midwives. At the end of the guide, we have suggested how you might consider the next steps you can take in your organisation or integrated care system (ICS) to strengthen your retention strategy through an action plan.

Understanding and using data

Read our dedicated section on understanding your data in our improving staff retention guide for guidance on what data you can access and how to use this, top tips, advice and case studies.

Understanding workforce data should be at the centre of an effective retention strategy.

The NHS Staff Survey has been redesigned to align with the People Promise elements. Analysing your results using this framework can help you to identify how well you are doing across a range of areas related to staff experience.

These can be used to help you make an initial evaluation of a particular category, such as flexible working or health and wellbeing support, in the self-assessment tool or can be used to monitor progress of your retention improvement plan over time.

To support you with this, see our nursing and midwifery retention self-assessment tool: staff survey questions which helpfully suggests key questions in the NHS Staff Survey that may support your self-assessment process (as used in 2021).

Professional development and careers

Ongoing professional development and internal career advancement opportunities are instrumental to maintaining engaged and professionally committed nurses and midwives.

Access to opportunities to learn and develop as well as support to allow nurses and midwives to reach their potential is key. Supporting our people to stay through career development opportunities is important across an employee’s whole career and should be based on an individual’s preferences and career aspirations.

Leaders can:

• Commit to investing in staff development and education. Seek to access and maximise national and regional funding opportunities that arise.
• Advocate for, and commit to, leadership development programmes to support diversity and inclusion. Join a leadership and lifelong learning course to grow as a leader.
• Ensure systems and processes encourage and support nurses and midwives to engage in continued professional development.

Managers can:

• Encourage shadowing and other work-based learning opportunities and cross team/cross profession working to stretch and develop skill sets, broaden skills and leadership capabilities and increase knowledge to support career progression.
• Hold coaching conversations with nurses and midwives about what is important to them including their short and longer-term career aspirations.
• Create an aspirational career development plan through personal development conversations and reviews such as one to ones. This will help strengthen skills in their current role, as well as being fully supported to flourish and grow towards the next step of their career.

Case studies

• University Hospitals Coventry & Warwickshire NHS Trust initiated careers conversations with their new healthcare support worker (HCSW) recruits to look at how they could best support them in their career journeys. Several employees had international registration who were interested in NMC registration and were unclear how to attain this. They designed and agreed a development programme to support a period in practice as HCSWs, a bespoke development plan and access to their OSCE preparation programme. They have so far successfully developed 10 people to become registered nurses and will continue to have career conversations with all new HCSW recruits.
   
• Dorset Healthcare University Foundation Trust designed their own online Band 2-4 career development platform and planning tool, ‘Brilliant Bands 2-4’ to support staff learning and development in both clinical and non-clinical areas. The accessible online resources support members of staff through their journey of finding a career pathway that is right for them within the organisation; both supporting staff development and retention. Read the full case study.
   
• Medway NHS Foundation Trust was experiencing significant challenges to recruiting nurses within the emergency department. The trust introduced several work-based educational programmes to support existing registered nurses to obtain a specialist award accredited at BSc or MSc level, including a support worker to nursing associate development pathway. Read the full case study.

Tools and further reading

• Preceptorship - Health Education England
• Career framework - Health Education England
• Professional nurse advocate programme
• Mental health career development framework - Health Education England
• The national nursing professional development - NHS Futures Platform
• Engaging and developing front-line clinical nurses to drive care excellence: Evaluating the chief nurse excellence in care junior fellowship initiative
• How implementing CLEAR revolutionised senior nurse’s thinking - NHS England

Further information

Read our dedicated section on development and career planning in our improving staff retention guide for more top tips, advice and case studies.

Flexible working

Flexible working supports our registered nurses and midwives to have greater choice in where, when and how they work and aims to support a healthy work-life balance.

Case study

• The Royal Free London NHS Foundation Trust introduced electronic self-rostering within their intensive care unit to offer staff greater flexibility and choice around shifts and support staff retention. This approach promoted roster fairness and enabled staff to have more control over their rosters, which improved work life balance and supported retention. Read the full case study.

Further information

For more information and advice, read our dedicated section on flexible working in our improving staff retention guide for top tips, advice and additional case studies.

Health and wellbeing

While the importance of supporting our NHS colleagues physical and mental wellbeing has long been recognised, now more than ever, supporting health and wellbeing should be integral to your organisation’s retention strategy.

Further information

For more information and advice, read our dedicated section on health and wellbeing in our improving staff retention guide for top tips, advice and case studies.

Pride and meaningful recognition

Pride and meaningful recognition are integral to motivating and retaining registered nurses and midwives and evidence shows can improve overall morale, job satisfaction and even relationships with patients.

Opportunities to recognise individuals for their ongoing dedication, commitment and day-to-day work should be promoted and can be done in a variety of ways. For example, celebrating good practice, significant career milestones, commending those who receive excellent feedback or by encouraging peer nominations to help thank colleagues.

Case studies

• Sherwood Forest Hospitals NHS Foundation Trust identified via its staff survey results areas of importance to its staff as well as areas for general improvement. A comprehensive recognition and reward package was developed and launched across the organisation to support its recruitment and retention campaign. Read the full case study.
   
• Nottingham University Hospitals NHS Trust as part of its professional revalidation process developed a peer review process that enabled registered nurses to gain direct feedback from a colleague. This enabled those working in similar roles to provide regular formal appreciative feedback for the individual. Using this information, staff were able to identify development goals as well celebrate their successes which were included within their personal development plan.

Further information

Read our dedicated section on rewarding and recognising your staff in our improving staff retention guide for top tips, advice and additional case studies.

Enabling excellence in care

We are enabled to lead and deliver high quality care

Ensuring systems enable the delivery of high-quality care is pivotal in retaining registered nurses and midwives. This includes those working in patient facing and non-patient facing roles. Evidence highlights the relationship between care excellence and retention; organisations that achieve better patient outcomes are also reported to be better at attracting and retaining nurses (Ball & Ejebu 2022).

Making this happen

Leaders can:

• Ensure trust strategies promote the central role nurses and midwives have in quality improvement, innovation and service development. Including nursing and midwifery teams in the development of these strategies is key to ensuring these meet the needs of our staff and our communities.
• Make sure systems and processes are in place to enable to identify staffing and other organisational resource requirements. This includes accessible data to support nursing and midwifery teams across your organisation and support the delivery of high-quality care.
• Enable opportunities to implement shared governance approaches such as shared professional decision-making councils.

Managers can:

• Ensure that data is used to support benchmarking as part of quality improvement approaches.
• Identify organisational and professional strategies supporting staff to contribute to them and ensuring local area work aligns to them.
• Create an environment where all members of the team have a voice that’s heard so that they can meaningfully contribute to decision-making and improving outcomes for staff and patients.

 Things to consider

• Do leadership cultures within the organisation encourage staff engagement?
• Are there professional and organisational strategies in place that identify and support the key role of nursing and midwifery in the delivery of high quality care?
• Are nurses and midwives given access to education and development that enables them to put their change ideas into practice?
• Is team working embraced and promoted to drive forwards transformational change from leaders at all levels?
• Is staff perception of culture understood, and is there a collective strategy to develop compassionate, fair and inclusive working environments where all staff can thrive?
• Is contribution to the delivery of high-quality compassionate patient care recognised and celebrated?
• Are working environments positive and supportive and do staff feel they can promote the delivery of high-quality care for patients?

Case studies

• Northampton General Hospital NHS Trust was the first in the UK to achieve Pathway to Excellence accreditation from the American Nurses Credentialing Centre (ANCC). Read the full case study.
• Nottingham University Hospitals NHS Trust (NUH) were the first organisation outside of the USA to be American Nurses Credentialing Centre (ANCC) Pathway to Excellence® and Magnet® recognised for excellence in nursing. Read the full case study.

Further information

• A range of resources and key steps related to shared professional decision-making.
• The Model Health System will provide data to support you with this topic, or alternatively review NHS Digital web pages for information on data streams.
• Nursing and midwifery excellence - NHS England
• Implementing ward and unit guide - NHS England
• In this video, nurses describe the components of excellence in care.

Shared governance and professional decision making

Collective leadership styles enable all nursing and midwifery teams to improve outcomes and experiences for our communities as well as supporting the professions to develop and grow.

They are about empowering nurses and midwifes to get involved and to know the value of their contribution. They are at the heart of the CNO’s call for the nursing and midwifery professions to speak with a bold, collective voice as #teamCNO.

Coming together through shared governance approaches embraces and values the diversity and experiences across the professions. A variety of terms are used to describe this way of working.

For example, ‘shared leadership’, ‘shared governance’, ‘distributed leadership’ and ‘shared accountability’ are commonly used. This illustrates the different ways that teams and organisation take forward leadership in this space.

These approaches places staff at the centre of the decision-making processes with managers having a facilitative leadership role (Haines, 2013), so managers can be assured that the voice of point of care staff are being voiced and acted on. The approach also allows managers to hear these concerns from staff themselves (Swihart, 2006).

The system empowers nurses and midwives to deliver high-quality patient care, independently and collaboratively, as equal members of the healthcare team.

Evidence suggests shared governance and decision-making models have the potential to change the traditional distribution of power which has significant impact on culture (Bamford-Wade & Moss 2010). This is effective when there is an alignment of strategies which foster power sharing across the hierarchy through distributed leadership.

Higher levels of distributed leadership have been shown to result in increased employee engagement, job satisfaction, and lower turnover intentions. Staff also describe feeling more empowered and committed to the organisation despite some challenges experienced in implementing the councils (Quek et al 2021).

A whole system approach and commitment however is required for the successful implementation of shared governance and decision-making.

Making this happen

Leaders can:

• Share their vision for shared governance and professional decision-making within their organisation, encouraging, enabling and empowering individuals to get involved.
• Identify opportunities for early implementation of shared governance models including supporting identification of key sponsors, supporters and stakeholders as well as identifying who will be the relevant senior support within an organisation.
• Consider how shared governance and professional decision-making aligns with an organisation’s strategies, values and behaviours and how each may influence the other and help foster a culture of accountability.
• Support the implementation of shared governance and professional decision-making education and training for nursing and midwifery staff.

Line managers can:

• Identify opportunities to establish shared professional decision-making councils and aid nurses and midwives to access training and education materials.
• Encourage, enable and empower their team members to participate in shared decision-making councils and have a voice within their ward or unit and in the organisation.
• Act as a role model demonstrating effective listening to others and positively supporting shared professional decision-making in their organisation.

Top tips/things to consider

A new guide is being developed on shared professional decision making that will be provided in due course. In the meantime, there are number of top tips for you to consider.

• The responsibilities of shared professional decision-making councils or groups and individuals within them and how they fit within existing governance structures.
• Consider what are the enablers. Be clear about the benefits; both for teams and for those receiving care.
• Engage and consult. There is compelling evidence the more engaged people can be, the more effective and productive they are, and most importantly, the higher the quality of care they deliver.
• Be flexible with shared governance and shared professional decision-making time and activities.
• Start small and grow from there.

Case study

• Since September 2020, University Hospitals of Leicester have been embedding the councillor model of shared decision making (shared governance) across the organisation. Although this is a continuous journey, many of the early adopters of this model have achieved successes individually and within their councils by implementing positive improvements in their areas. This in turn has led to those staff feeling much more empowered and engaged and increased retention.

Further information 

• Shared professional decision-making: putting collective leadership into practice - NHS England
• Nursing research and evidence underpinning practice, policy and system transformation - NHS England
• CNO shared governance: collective leadership programme - NHS England
• Principals of shared professional decision making.
• Nursing directorate catalogue of change will give you case studies from a wide range of organisations on ideas and innovations adopted during difficult times - NHS England

Leadership

Compassionate and inclusive leaders can set the cultural tone within an organisation and play a key role in helping improve and influence the working environment for all colleagues. Research shows that the most powerful factor influencing culture is leadership.

Leaders contribute to enjoyment at work and overall satisfaction when professional relationships are built on trust and psychological safety, promoting a sense of belonging which has a considerable influence on retention.

Making this happen

Leaders can:

• Be a role model to encourage engagement with the self-assessment tool and retention activity across the organisation, listen and understand what will make a difference for people through shared professional decision making.
• Encourage system collaboration on creating an inclusive leadership culture and connecting on retention to support the wider strategy within the region, focusing on key priorities and having oversight of dashboard data.

Line managers can:

• Role model an inclusive culture where nurses or midwives feel they are supported and have a voice, as well as empower to make decisions.
• Share and celebrate successes across the organisation, to encourage others and help people feel valued.

Case studies

• Gloucestershire Hospitals NHS Foundation Trust set up their GloSTARS peer support network to improve the retention and wellbeing of newly registered nurses, registered nursing associates, overseas nurses, and newly qualified allied health professionals who are at the start of their careers. GloSTAR guardians wear a special badge and offer expertise for different career pathways and can provide formal and informal guidance by signposting potential opportunities or continued professional development advice. Read the full case study.
   
• Listen to NHS Employers’ podcast to hear how great leadership at the Isle of Wight NHS transformed the organisation. Hear from Maggie Oldham former chief executive, Jen Edington, director of nursing, Karen Caramat, ward sister and seven-year-old Matilda and her mother Lisa Garnham, health and wellbeing lead, who share what it was like to work at the Isle of Wight in 2016 and throughout the pandemic and how the culture was changed to improve the staff experience.

Further information

• Join NHS England’s Culture and Leadership Programme which provides opportunities for organisations to understand their own culture using evidence-based tools, develop tailored leadership strategies for developing compassionate, inclusive and collective leadership and deliver culture change.
• Access NHS Leadership Academy for further information
• Read NHS Employers' blog written by Professor Michael West on teamworking, psychological safety and compassionate leadership.

Developing your retention improvement plan

In this section, consider the steps that you can take in your organisation to strengthen your retention strategy. This section will support you to develop an evidence-informed retention plan built on improvement methodologies, which can be implemented locally or in collaboration with system partners.

It will help you plan and successfully implement actions or activities that leaders and managers can take to drive progress in retaining our nurses and midwives. Dedicated guidance on how to effectively evaluate the impact of your retention activities will help ensure you can evidence success and refine your efforts where needed.

Making improvement and change

As part of the planning stage of your retention activities, and to help create an environment where change programmes deliver transformational, sustainable change, you may wish to consider the Change Model Framework.

The model provides a useful framework for sustainable change and transformation that delivers real benefits for patients and the public.

Things to consider

• What constraints in your organisation prevent line managers and teams becoming involved in retention activities?
• Could line managers and teams help to break down their activities into smaller short-term actions which are more manageable and together lead into a long-term vision? This may also help build trust and minimise concerns by helping line managers and teams to break the long-term vision into shorter-term actions for making change.
• How can information and stories be used to connect in a diverse way to get line managers and teams appropriately engaged? Use examples of issues that are currently minor and explain how they can become major challenges for teams in the future if left unresolved.
• Encourage managers to create the vision for their team or department. The process is as important as the vision itself, as it gives everyone time to consider the change, what it means for them, and to voice any concerns.
• Where the change may be perceived as negative, talk openly about it to build trust. Also value your sceptics as they may help identify things you may have missed.

The improvement capability building and delivery team, which is part of NHS England’s Transformation Directorate, helps build capability in teams, organisations and systems to improve services to enhance patient care, driven by evidence-based, policy-aligned improvement capability building.

A dedicated improvement hub sets out a wealth of improvement knowledge, information and tools to support the delivery of sustainable service improvement.

Top tips

• Speak with your improvement lead about ways you can work together to improve workforce retention.
• Consider the different improvement tools that are available and answer the questions set out here to help inform your thinking around the planned change.
• Continue the dialogue over time so that line managers and teams stay engaged and up to date with changes and continue to see the benefits to them.
• Role model both the values and behaviours needed to create transformational change within your organisation.
• Taking time to slow down and observe what is going on in your departments will give you the opportunity to gain real insights into what is happening for staff and patients on the shop floor.

Tools and further reading

• Keep up to date with interventions and practical solutions on NHS England’s website.
• A driver diagram is a visual activity for tackling complex issues like retention and can be used to plan improvement project activities.
• NHS England’s Change Model Framework.

Next steps

Following completion of the self-assessment tool and identification of areas of focus for further work it is important to consider next steps.

Things to consider:

• Are your targets specific, measurable, achievable, relevant and time-bound (SMART)?
• Do you have robust evidence to suggest your action will make a difference?
• Can you focus your attention on two or three key areas of improvement rather than trying to tackle everything at once?
• Are the timescales you have set realistic?
• When setting your actions, have you considered the personal, team and organisational behaviours that may block your progress?
• Have you identified the best person to take each action forward and worked with them to get them onboard?
• How regularly will you check-in to ensure the actions are completed on time?
• How do these actions fit in with the retention priorities of your ICS?

Action plan

Create your own retention improvement plan either using your own internal template or you can adapt this template.

Evaluating impact

When planning your retention strategy, consider how you are going to evaluate the impact of the changes you intend to make.

Being clear about what you want to achieve at the outset. Making time to regularly review your activities will help you to assess how successful your strategy has been and whether any changes need to be made.

Evaluating your activities will also help in better communicating what your organisation is doing around retention and the value it has. It will also help identify any risks and issues and recognise where you have done good work.

The following evaluation process will allow you to think through how you will measure the impact of your retention activities from the start.

How to evaluate impact:

1. Define your objectives
   • Make sure they are clear, measurable, and relevant to your staff groups, team or organisation. Getting your objectives right at the beginning will make it easier to measure them throughout.
2. Identify your stakeholders
   • This will be all the people who will be affected by your retention initiatives. Consider who you can work with collaboratively to deliver your retention activities, such as your improvement team and organisational development leads, and identify the benefits you hope to achieve.
3. Map tasks and activities
   • Think about what activities you will carry out to meet your objectives and how each of these will help influence the behaviour of your stakeholders.
4. Define your performance measures
   • To assess performance against retention activity objectives, you will need to identify which elements of the activities worked well and which worked less well. Think about impact and outcomes as well as financial or staff turnover targets.
5. Identify data sources
   • Identify, for each performance measure, what data you will use and how you will source it. Make use of tools, such as the electronic staff record (ESR), exit interviews and feedback from staff.
6. Identify risks and constraints
   • These will include financial risks and resources, and the time and capacity of staff you’re asking to support your retention activities.