Explaining nursing attrition through the experiences of return-to-practice students: a mixed-methods study

High attrition rates in nursing, which have adverse effects on staff: patient ratios, workload, patient safety and care quality, are a global problem (Aiken et al, 2002; 2014; 2018; Royal College of Nursing (RCN), 2015). In 2020, the World Health Organization (WHO) estimated a global nursing and midwifery shortage of 5.9 million, concluding this to be damaging to the health and wellbeing of entire populations (WHO, 2020).

Nurse scarcity and maintaining an adequately skilled workforce are concerns of healthcare employers internationally (Price, 2009; McLaughlin et al, 2010; Jirwe and Rudman, 2012; Perry 2012). In the UK, NHS England/Improvement (2019) suggested that greater attention needed to be paid to why nurses leave the profession, as a large-scale investigation had evidenced the harmful association between levels of nurse staffing and the calibre of nurse education, staff burnout, patient outcomes and patient mortality (Aiken et al, 2014); indeed, Aiken et al (2014) reported that one additional patient on a nursing workload increases the likelihood of another inpatient dying by 7%.

In 2014, Health Education England (HEE) (2014) reported that 10% of the nursing workforce was seriously considering leaving the profession. In 2020, a survey of 42 000 RCN members indicated that such considerations had been exacerbated by the COVID-19 pandemic, with 36% of respondents now thinking of leaving the profession (RCN, 2020). Among the reasons cited were level of pay, working at a higher level of responsibility, low staffing levels and lack of management support. Although a majority of respondents confirmed feeling more valued by the general public, patients and service users, only 18% reported feeling more valued by government at a time when they felt they were having to work even harder than previously.

The inability to retain nurses and midwives inflicts significant financial penalties upon healthcare organisations (Li and Jones, 2013). Poor retention necessitates recruitment, selection, training and staff support, increasing direct costs. Other undesirable consequences accrue through workplace turbulence, including additional work being imposed upon existing staff which, in turn, gives way to lower job satisfaction and morale, all leading to a poorer quality of patient care (RCN, 2021).

These concerns pose continuing challenges for policymakers and planners in high- and low-income countries alike (International Council of Nurses, 2006). Despite attempts to plan strategically to retain the nursing workforce (Mbemba et al, 2013; Twigg and McCullough, 2014), healthcare employers internationally experience, at best, cycles of significant shortages, requiring short-term solutions such as actively poaching nurses from other countries (Lintern, 2013).

Arguably, the generation and sustainability of any nursing workforce depends on two pre-eminent considerations, namely effective recruitment and then successful retention of the most capable staff (Centre for Workforce Intelligence, 2012).

HEE is the arm of government charged with maintaining the safe staffing of the NHS in England. The vast majority of NHS staff work in acute hospitals, although, over time, there is a policy to develop more care closer to home. To fulfil this objective, HEE has sought to bring back to practice registered nurses and midwives who have chosen, for whatever reasons, to leave the profession (Price, 2009) through the Return to Practice (RtP) campaign (Health Foundation, 2014; HEE, 2021).

In England, nurses who have practised fewer than the required number of hours over a 3-year period are not legally able to re-register with the UK's regulatory body, the Nursing and Midwifery Council (NMC), and are therefore not able to practise as registered practitioners (NMC, 2019). Irrespective of the length of time since registration lapsed, individuals who have not completed these hours in the previous 3 years must successfully complete an RtP programme approved by the NMC before they can rejoin the nursing register.

In academic terms, the RtP programme is viewed as a good investment. It attracts nurses who often have significant professional awareness, clinical expertise, life experience, transferable skills and an appetite to address the needs of the service; it may bring people into the profession at lower costs than conventional nurse training programmes.

The successful relaunch of the RtP campaign in 2014 provided a unique opportunity to examine attrition from the perspectives of nurses who had left the profession and were now re-engaging through a RtP course. With this in mind, this study was designed to gain a detailed understanding of: why nurses had left registered practice; why they had let their registration lapse; and their aspirations as returners. It also intended to gain broader insights to develop a better understanding of nursing retention to inform future nursing retention strategies.

Literature review

Simon et al (2010) undertook a study with a sample of 2119 registered nurses in a variety of departments in 16 German hospitals, and found the general considerations that swayed the decision to leave nursing were low job satisfaction, advancing age and a decline in professional commitment. Distinctively personal elements linked to leaving nursing were individual background and the inability to manage work/life balance. Other researchers have determined burnout to be the strongest predictor of practitioners' intentions to depart (Chan et al, 2013; Choi et al, 2013; Aiken et al, 2014; Ishihara et al, 2014; Rudman et al, 2014), or the related concept of moral distress (Torjuul and Sorlie, 2006). Against this background, decreased job satisfaction becomes cumulative until the decision to leave becomes foremost (Li et al, 2010; Barlow, 2014; Whitehead et al, 2015).

Frequently, insufficient resources (mainly staffing but also equipment and facilities) have been found to be a root cause of nurse wastage, compounded by an unsupportive managerial culture and poor professional relationships, all of which contribute to suboptimal levels of care and the subjective practitioner experience of detachment from patients and carers (Estryn-Beher et al, 2010; Choi et al, 2013). The work environment is much cited in exit interviews as a leading precipitant of attrition, and this often characterised by poor peer support, weak management and an institutional blind eye being turned to suboptimal care (MacKusick and Minick, 2010; Currie and Carr Hill, 2012).

Stress arising from a challenging interface between work and home is often reported as a precursor to staff attrition. Researchers have observed that, if there is sufficient dissonance between the competing demands of the two, then deciding to leave nursing becomes more likely (Li et al, 2011; Uğur Gök and Kocaman, 2011; Bogossian et al, 2014). Leaving to care for a dependent family member is also common (Estryn-Behar et al, 2010).

The often-quoted association between poor working relationships, burnout and attrition are well understood (Ishihara et al, 2014). However, these can be significantly reduced when participants experience remedial measures in their workplace through peer support and supervisory and managerial backing that is respectful, provides prompt feedback and confers authority and responsibility to make decisions (Zhang et al, 2014).

Nurse age has also been linked to retention and attrition. Li et al (2011) observed that nurses working in a hospital environment aged 25 and above with a minimum of 5 years' experience were more likely to remain in their career. Conversely, Flinkman and Salanterä (2015) and Rudman et al (2014) found that 20% of nurses intended to leave within 5 years of qualifying, regardless of age. Those who leave are often sufficiently dissatisfied by their experiences, are poor advocates for the profession and are likely to counsel others against entering it (Skillman et al, 2010).

Methods

A two-phase, sequential, mixed-methods design was adopted (Cresswell, 2013). This comprised administration of a questionnaire (phase 1: quantitative method); and telephone interviews with a subsample of questionnaire respondents (phase 2: qualitative method).

Phase 1. Quantitative questionnaire

A researcher-generated questionnaire was distributed to all students taking part in one of the RtP courses at the four collaborating institutions starting between June 2015 and April 2016; there were a total of 160 RtP participants within the HEE commissioning area. To improve accessibility, the questionnaire-based data collection tool was provided in both electronic and paper formats.

Questions were informed by the literature review, and generated quantitative information for descriptive and inferential statistical analysis. They elicited responses relating to the date of completion of initial training, level of educational attainment, years worked as a nurse, grade when registration lapsed, domain of practice and reason for leaving and returning to practice. Open-text opportunities were offered to respondents as appropriate and these responses were analysed in a second, qualitative phase of analysis.

Quality review and validity checks were addressed by consultation with an expert advisory group, including representatives from professional, academic and commissioning interests. There was statistician input to inform the instrument design and ensure data were measurable, and a pilot study with a group of students and academics was carried out to assess the acceptability of the tool.

Phase 2. Qualitative interviews

A series of in-depth, semistructured telephone interviews were conducted to explore the factors that influenced decisions to leave the profession (n=20). Sampling for this phase was informed by phase 1 data, with selection from participants who had said in the questionnaire that they were prepared to be contacted for interview. Of interested participants, at least two were selected from each reasons for leaving category responses from phase 1.

Semistructured interviews were undertaken by two members of the project team (JG and JH), who were both senior nurses and experienced interviewers. Questions were guided by the literature and phase 1 initial findings and, for consistency, interview prompts were agreed by the advisory group before data collection. After participant consent had been gained, 20 interviews were undertaken. Recruitment and interviewing were continued until data saturation had been achieved.

Ethical considerations

The research team had neutral relationships with the four participant institutions and no involvement with the RtP programmes under investigation. Ethical approval to proceed was secured from the University of Huddersfield and from all participant institutions.

A study information sheet was distributed to individuals before both phases, and written consent was received before data collection began. All data from participants relating to their university and employer organisations was anonymised and respondent privacy and confidentiality were preserved at all stages of data collection, transcription and analysis by allocating each person a unique identifying number.

Data analysis

The quantitative data analysis procedures comprised: descriptive analysis of trends and variables in data relating to reasons for leaving nursing; and inferential assessment of significant associations for ceasing to practice.

Quantitative data were analysed using SPSS v24 statistical software. Qualitative data were transcribed and analysed using NVivo software guided by a framework analysis technique (Ritchie and Lewis, 2003; Gale et al, 2013). Following transcription, data were sifted, charted and coded, and sorted into key themes in a 5-step sequential process: familiarisation; identification of a thematic framework; indexing; charting; and mapping and interpretation (Ritchie and Spencer, 1994). Analysis was undertaken independently by two members of the research team.

To identify coexisting findings, the qualitative and quantitative data from both phases were compared for complementary findings and contrasted with contradictory evidence through triangulation; codes were mapped and themes subsequently ratified by the advisory team.

Results

Quantitative analysis

There was a 71% response rate, with 114 questionnaires returned from respondents. Of the respondents, 102 (89.5%) were female and 12 were male (10.5%). The distribution of work settings represented a fair approximation of the English nursing population as a whole, most of whom work in hospitals. Sample characteristics are summarised in Table 1.

The distribution of years served in the profession was bimodal: while 30 (26.3%) nurses left the profession after 5 years or fewer, a substantial number (n=59; 52%) left after 10 years or more. Relatively few (n=8; 7%) left between 5 and 10 years.

Phase 1 revealed a trend among those who had worked as a nurse for longer periods of time to enter part-time rather than full-time employment during their vocational break. Those who took up part-time employment (n=17) had worked for an average of 12.0 years (SD 6.0 years), while those who took up full-time employment (n=48) had worked as nurses for an average of 9.1 years (SD 6.4 years).

There was a strong association between the number of years worked as a nurse and the setting in which the nurse worked. Those based in hospitals worked for a mean of 8.23 years (SD 6.17 years) before leaving, the shortest period of time of any of the four work settings represented. Those who had been community based worked for a mean of 13.1 years (SD 6.95 years) before leaving the profession. Consequently, those based in the community worked on average 4.86 years longer than hospital nurses before leaving the profession.

Disregarding those who described their role as management or other, an independent sample t-test was conducted to assess the significance of the difference in years worked between nurses based in hospital and community settings. The difference of 4.86 years was statistically significant at the 5% significance level (P=0.024; CI 95%[0.68–9.05]).

Qualitative analysis

Twenty telephone interviews were conducted, which lasted from 25 to 64 minutes.

Although recognising the challenges and pressurised nature of their initial nursing role, many participants reflected very positively on their previous vocation. Positive elements of a nursing career reported included professional camaraderie, supportive management, public esteem and a fervour for the job. One participant typified this view:

‘It was such a privilege to be in a role like that … that's never left me … I'm passionate about nursing.’

RtP_20

Exploration of the rationale for leaving during phase 2 revealed three recurrent themes: family; career development; and trigger incidents (ie an incident precipitating a decision by a nurse to leave the profession). Putting family first was a paramount concern of respondents that influenced their inability to continue in nursing. Despite enthusiasm for a nursing career, a lack of support for childcare was an influential determinant of attrition, with a combination of unsupportive childcare arrangements and inflexible shift patterns seriously impeding the ability to both be an effective parent and maintain the equilibrium of a work/life balance:

‘It was a sad day when that happened, but it was just, it had to happen and I put my children first, the family first … that was just how it was.’

RtP_13

‘So I did ask … to do something like a 9 till whatever shift … but they wouldn't accommodate. So, because they didn't accommodate … that forced me to leave.’

RtP_10

A number of participants indicated that they decided to prioritise their partner's career:

‘My husband moved job, so we ended up moving away from the area, which is why I had to leave.’

RtP_14

Several participants whose professional registration had lapsed were unhappy with the professional restrictions that had resulted from career moves and attributed losing their registration to this; some had achieved levels of managerial seniority that took them away from direct patient care. Some individuals remained in the NHS while others moved to alternative settings related to the health service:

‘My role didn't specifically require me to be a nurse … in discussions with the NMC, they were adamant that you couldn't re-register without having a specific number of [hours of] actual hands-on clinical practice.’

RtP_02 (working in the NHS)

‘A letter arrived saying “you're now off the register” and I thought, well, the job is now done. But, actually, I knew within 6 months [of losing registration that] I could have stayed on the register.’

RtP_16

Several participants reported individually evocative events as part of personal or professional experience that triggered the desire to leave. Several narrated personal traumas:

‘My youngest had a [life-threatening illness and] suddenly became really poorly … my other priorities took over.’

RtP_18

Unavoidably, such career breaks led to a lapse in registration, which meant individuals were unable to return to nursing once their crisis had passed. Several participants described serious instances of poor management support that precipitated burnout and moral distress, which triggered their departure:

‘One particular experience … I was left running the [unit] on my own and it was bedlam … I asked for help and they basically told me to get on with it myself [then] I can remember going to a side room finding that my … patient had died on his own … walking home that night after that late shift just crying and crying, thinking I can't do this, I just can't do this, and I handed in my notice … it was such an awful experience.’

RtP_12

Many participants who had continued in employment remained in health-related or caring roles. Most highlighted how they still relied on their nursing experience. Everyone told a different story. Of those continuing employment within healthcare, one said:

‘I've always … worked for the NHS … so I've never been out of the NHS since qualifying.’

RtP_02

‘It's an [NHS project] coordinator, so it's a regional role to implement [the project], national government led …’

RtP_08

The flexibility to balance work and life demands was important for one participant who worked for a healthcare research company but stayed there also because the salary was attractive:

‘I've progressed up to project management … because of the flexibility with my family and the fact that it's a great deal more money than nursing.’

RtP_09

Many participants remained in employment throughout their break from nursing, despite not being registered, but still drew on their nursing experience:

‘Although I wasn't still registered, in view of my clinical training … I've had all sorts of roles on the back of being clinically trained.’

RtP_16

An exploration of why the participants had decided to return to nursing through a RtP programme showed commonalities in feedback from many, particularly those who had left for childcare reasons and aspired to return to the profession. Their families were growing up, which furnished them with personal choice and the opportunity to return:

‘My youngest two were about to go into primary school … everything that I looked at, it didn't seem worthy in comparison to nursing … I just felt like I wanted a worthwhile job … I wanted it to make a difference to me, my family.’

RtP_01

‘You know, my children are older now, I've got a chance to look at what I really enjoy and what's best for me, rather than just what's best for the family.’

RtP_09

Discussion

This research presents a unique study of attrition through the diverse experiences of nurses who had left the profession and chosen to return through an RtP programme. It is recognised that this is a unique group and these study participants are different from nurses who have left the profession completely.

Two distinct categories of participants are apparent: those who left registered nursing practice for personal reasons through an unmanageable disequilibrium of their work/life balance; and those lacking the opportunity to advance in their career and maintain their nursing registration simultaneously.

The mean reported age of 46.5 years, in conjunction with a mean period of 9 years out of nursing, implies that many or most were leaving the profession in their 30s. This is a significant concern for workforce planning as these leavers still have many years of working life ahead of them. There is, nevertheless, little evidence to indicate that age alone is a significant precursor of attrition, although Heinen et al (2013) identified that older nurses and those working part time were more likely to leave the profession than younger and full-time workers. The present study does, however, resonate with the previous findings that shift patterns appear to become more difficult to manage with increasing age, and contribute more strongly to the decision to leave by older, more experienced nurses (Gurková et al, 2013; Bogossian et al, 2014). The findings of the current study also concur with those of Baum and Kagan (2015) in that it indicated a greater intention to leave among younger nurses under 35 years of age, regardless of working environment.

The typical nurse who took part in this research had accrued nearly 10 years of experience before leaving the profession. While recognising the challenges and the busy nature of the role, many reflected positively, with a clear appetite for and commitment to nursing. This finding contrasts with the wider body of literature, which indicates that burnout and a lack of resources are the fundamental reasons why nurses leave the profession (Rudman et al, 2014).

This study repeatedly highlighted that significant personal or professional incidents causing moral distress precipitated the departure from nursing. Individuals discussed the need for time out to cope with these; many of them experienced often short-lived but nevertheless life-changing events. According to their testimonies, many participants would not have departed and let their registration lapse had appropriate managerial and pastoral support been available at their time of crisis.

The timing of the participants leaving the profession demonstrated an interesting bimodal pattern. Many nurses left the profession after less than 5 years of experience in the profession yet relatively few left between 5 and 10 years. There was then a further increase after 10 years or more. This supports the theory that the first 5 years of employment is when a nurse is most susceptible to attrition (Crow and Hartman, 2005; Currie and Carr Hill, 2012).

The most common reasons given by participants for departing the profession were childcare or caring responsibilities. However, as answers to a supplementary question indicated, these nurses were not all leaving to become carers. Rigid shift patterns conflicted with the ability to fulfil family responsibilities and were a strong indicator of likely attrition. This finding concurs largely with those of Simon et al (2010) and Skillman et al (2010), although these authors reported shift patterns accounted for nurses changing position as well as leaving altogether. Conversely, however, some nurses testified that shift working, when judiciously organised, can provide an acceptable work-life balance. As elsewhere, the weight of opinion sustained the view that shift work can be a potent cause of some nurses seeking alternative employment (Bogossian et al, 2014).

The finding of the current study that 83% of participants stay in employment during their vocational break raises the question of why so many participants felt forced to leave nursing, yet were adequately able to work in alternative employment during their absence from the profession. The study also found hospital nurses were leaving significantly earlier than those working in the community.

The findings of this study are consistent with those elsewhere, demonstrating that a need for increased financial security for participants and their families is a decisive reason for leaving nursing for alternative healthcare roles (Uğur Gök and Kocaman, 2011). Similarly, this study identified a trend that more of those with less than 5 years' nursing experience were leaving because of profession-related issues. A career change was the most common alternative reason for participants with less than 5 years of experience to leave, yet Skillman et al (2010) reported that greater flexibility in working hours, changes to workload (a reduction in the level of physical work and fewer numbers of patients to care for) and pay were give as incentives to return. Many participants emphasised how caring for children had adversely affected their nursing career because they simply could not afford childcare or lacked support networks to help out with their children; this all indicates the inflexibility of health service organisations when it comes to recognising the obvious stress on staff with maternal responsibilities.

Additionally, although several participants' nursing registration had lapsed, six of those interviewed were still working in the NHS or health professional settings, but with roles that had progressed in either specialist or managerial positions, where they may not have had enough direct patient contact hours deemed by the NMC for retention of registration. Several had had discussions with the professional body, which had advised they were not working in traditional hands-on roles and therefore could not re-register.

Most published research has evaluated the views of nurses still working in practice yet expressing an intention to leave either their employing organisation or the profession as a whole. This intention to leave the profession or an organisation are clearly separate considerations yet are difficult to differentiate. It is important to recognise that leaving one organisation while retaining the commitment to healthcare generally within another organisation may be in evidence of career progression and development rather than a loss to the profession.

The factors influencing nurses leaving or intending to leave are multifaceted, with nurses working in an environment where it is perceived that there are insufficient resources to provide optimum care and they are persistently asked to work long and inflexible hours. These reasons, however, are clearly more complex than a simple analysis of nurse:patient ratios and/or staff skill mix can illustrate, with patient dependency and complexity of need being just two further variables requiring consideration. What might make nursing an attractive career needs further exploration, as there is not always a clear understanding of the influences on an individual's decision to remain in the nursing profession (Cho et al, 2010; Cowin and Johnson, 2011).

Conclusion

Nurse attrition is an established phenomenon with a multifarious aetiology. Choi et al (2013) acknowledge that, while addressing nursing shortfalls may necessarily require strategic planning and increased investment in supporting the current workforce, there are organisational changes that could positively influence the labour deficit. Organisations and employers undoubtedly need to be more flexible and find creative solutions to demonstrate the valued contribution nurses make. It is therefore essential to recognise the expertise, education, level of competence, leadership, patient focus and support of others that this professional group brings to the workplace.

There is a need to establish detailed dialogue with follow-up actions so staff feel better supported. Nurses need to feel appreciated and be heard and understood, both as competent professionals and as individuals. Nursing is best understood as a vocational occupation that, for right or wrong, has often been articulated through concepts of motherhood. This does, however, behove those managing the nursing workforce to recognise that this notion of caring is integral to the personal integrity of practitioners, permeates their personalities and extends way beyond the workplace and it calls for somewhat more supportive working environments then hitherto.

Enabling professionals to maintain a healthy work/life balance requires a root-and-branch review by employers on the flexibility and fairness of duty rotas, particularly in the light of the finding that the primary reason for nurses leaving their profession is childcare or other caring responsibilities. Unsocial hours are an inevitable and undeniable demand on all, and decisions will always be difficult to make. Presenting staff with unworkable propositions should be avoided in an atmosphere that ought to be fostering trust and transparency.

There is a need to differentiate between attrition and turnover with greater specificity. Exit interviews need to be facilitated by staff who are able to implement change and initiate opportunities to support and retain nurses so they maintain their professional registration.

Contemporary health-provider organisations require nurses to play a unique role as champions of care quality, have enthusiasm for managerial and professional accountability and standards, and take leading roles in the effective delivery of local health services (Prime Minister's Commission on the Future of Nursing and Midwifery in England, 2010; Willis Commission, 2012). This requires a greater understanding by policymakers and service managers of what motivates nurses to remain in practice. The finding in particular that nurses in hospitals are leaving the profession significantly earlier than those in community settings points to a specific need for dialogue between nurses and managers in hospital settings.

KEY POINTS

• There are two main reasons why nurses leave the profession: personal because the work/life balance becomes unmanageable; and a lack of opportunity to advance in their careers while maintaining their registration
• The most common reasons given by participants for departing the profession were childcare or caring responsibilities; however, many of these individuals did not become carers but found employment elsewhere
• A high proportion of nurses in this study left the profession in their 30s; this is a significant concern for workforce planning, because this age group has many years of working life ahead
• Significant distressing incidents, personal or professional, can precipitate nurses to quit. Many would not have departed and let their registration lapse had managerial and pastoral support been available at a time of crisis

CPD reflective questions

• What can you do to maintain a manageable work/life balance?
• Consider how colleagues could be supported after distressing incidents
• How might the findings of this research change your practice?