PROFESSIONAL
Factors influencing retention among
hospital nurses: systematic review
Takawira C Marufu, Alexandra Collins, Liavel Vargas, Lucy Gillespie and
Dalal Almghairbi
ABSTRACT
Background: Recruitment and retention of nursing staff is the biggest workforce
challenge faced by healthcare institutions. Across the UK, there are currently
around 50 000 nursing vacancies, and the number of people leaving the
Nursing and Midwifery Council register is increasing. Objective: This review
comprehensively compiled an update on factors affecting retention among
hospital nursing staff. Methods: Five online databases; EMBASE, MEDLINE,
SCOPUS, CINAHL and NICE Evidence were searched for relevant primary
studies published until 31 December 2018 on retention among nurses in
hospitals. Results: Forty-seven studies met the inclusion criteria. Nine domains
influencing staff turnover were found: nursing leadership and management,
education and career advancement, organisational (work) environment, staffing
levels, professional issues, support at work, personal influences, demographic
influences, and financial remuneration. Conclusion: Identified turnover factors
are long-standing. To mitigate the impact of these factors, evaluation of current
workforce strategies should be high priority.
Key words: Nurse recruitment  ■ Nurse retention  ■ Staffing levels  warned of the current and future impending crisis in nursing staff
■ Nurse shortages  supply, stemming from a lack of adequate workforce planning,
N
urses are fundamental in ensuring the delivery
of high-quality care in healthcare institutions.
Globally, there are an estimated 29 million
nurses and midwives (Wong et al, 2015),
who constitute the largest group of health
Takawira C Marufu, Clinical Academic Lead Nursing Research,
Nottingham Children’s Hospital and Neonatology, Nottingham
University Hospitals NHS Trust, takawira.marufu@nuh.nhs.uk
Alexandra Collins, Practice Development Lead for Wider Workforce,
Institute for Nursing and Midwifery Care Excellence, Nottingham
University Hospitals NHS Trust
Liavel Vargas, Health Education England East Midland Professional
Fellow—Career Development and Retention, Nottinghamshire
Nursing and Midwifery Cabinet, Institute of Nursing and Midwifery
Care Excellence, Nottingham University Hospitals NHS Trust
Lucy Gillespie, Practice Development Lead for Recruitment and
Retention, Institute for Nursing and Midwifery Care Excellence,
Nottingham University Hospitals NHS Trust
Dalal Almghairbi, Lecturer in Anaesthesia Department, University
of Zawia, Libya
Accepted for publication: August 2020
302
professionals within healthcare organisations. However, over the
past decades, nursing shortages have become a global challenge.
Across the UK, there are around 50 000 nursing vacancies in
total: 43 615 in England, 3060 in Scotland, 1612 in Wales and
1671 in Northern Ireland (Royal College of Nursing (RCN),
2020; RCN Northern Ireland, 2020; RCN Wales, 2020).
In 2019, the total number of registrants who left the Nursing
and Midwifery (NMC) register was 27 589, which included
both UK-trained and non-UK trained nurses, a figure that was
23% higher than in 2013 (RCN, 2020). Such a reduction in
nurse numbers inevitably puts patient safety at risk, as well as
the quality of the care provided, it also decreases efficiency. In
addition, reduced staff numbers affect staff morale, the health
of individual nurses, and increase costs for organisations,
which have to continually recruit and train new employees to
replace those who have left (AbuAlRub et al, 2009; Perreira
et al, 2018).
Previous similar reports to the latest RCN workforce review
workforce strategies and policy initiatives. Nursing retention
is influenced by economic, organisational, environmental
and personal factors. Identification and quantification of
these issues, in order to mitigate their effects, is imperative.
Although policymakers are focusing on opening new routes
to nursing, actions must also be taken to address the perennial
challenges that have, and will, cause nurses to leave their jobs
or the profession before they reach retirement age (AbuAlRub
et al, 2009).
Consistency in high turnover rates within the nursing
profession and associated costs have been documented in the
literature (Helm and Bungeroth, 2017). Nurse turnover rates
vary across nations: in Jordan it is 36.6% (AbuAlRub et al,
2009), in Canada, 20% (Clancy, 2007), in the UK 17.5% (NHS
England and NHS Improvement, 2019), and in the USA 17.1%
(NSI Nursing Solutions Inc, 2020). In European countries,
the rates range between 12% and 21% (Li and Jones 2013).
Several studies in the 1990s argued the benefits of effective
nursing management and leadership as having positive influences
on nurse retention (Dunham and Klafehn, 1990; McDaniel
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and Wolf, 1992).
Clinical experience and the literature show that the most
common factors that affect retention in nursing have remained
relatively unchanged for more than 30 years. According to
Health Education England (HEE), the current single biggest
British Journal of Nursing, 2021, Vol 30, No 5
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workforce challenge is the inability of healthcare institutions

to stop nurses leaving their jobs (Mitchell, 2018). Therefore,

Identification
the purpose of this review was to compile a comprehensive Records identified through
update on the factors that affect the retention of nurses within database searching
the ever-changing professional landscape. (n=4864)

Method
The Preferred Items for Systematic Reviews and Meta-Analysis
(PRISMA) checklist and flow diagram were used to design
Records afrer duplicates
and report the review process (Moher et al, 2015) (Figure 1). removed
(n=2726)
Search strategy

Screening
A systematic literature search was performed across five online
databases: CINAHL, EMBASE, MEDLINE, and SCOPUS
(via Ovid platform), and NICE Evidence Search. The search Records screened Records excluded
strategy was tailored to the individual database. A combination (n=442) (n=374)
of Medical Subject Headings (MeSH) and free-text terms
were used to increase sensitivity for identification of potential
studies. Search terms used were recruitment* OR retention*
OR nurse* and factor* OR influenc*. These terms were
Eligibility

initially run individually and then combined in each database. Full-text articles assessed for Full-text articles excluded, for
eligibility the following reasons:
Hand searches were also conducted by searching the reference
(n=68) 5 did not focus on
list in studies identified for inclusion through an electronic ■
recruitment and retention in
record search.
nursing
■ 9 focused in recruitment and
Eligibility criteria retention of nursing students
The review was based on peer-reviewed published studies only. ■ 5 focused on recruitment
and retention in rural health
Included

All primary research papers considered had primary or clear
secondary aims focusing on factors influencing the retention
of nurses in hospitals. No limits were applied; all databases were
searched up to November 2018. Studies in other languages
were considered if an English translation version was available.
Reviews, descriptive articles, case studies, letters to the editor
and opinions were all excluded.
Study selection
The online search strategy was performed by one of the authors
(DA). Selection of potential studies for inclusion both at title
and abstract stages was independently implemented by DA
and TM in accordance with the eligibility criteria. Neither
reviewers were blinded to the study authors and journal
titles. Disagreements between the reviewers were resolved by
discussions and/or the input of one of the other authors.
Data extraction and methodological quality assessment
Data extraction and quality assessment were performed
individually by four reviewers (DA, AC, LG, and LV), with
disagreements resolved by discussion and the involvement of
a fifth reviewer (TM). Data variables from individual studies
included: country of study, participants, sample size and the
retention factors identified. All data were entered on a pre-
piloted Excel spreadsheet.
© 2021 MA Healthcare Ltd
Studies included:
care
(n=46) ■ 3 focused on recruitment
only
Figure 1. Flow diagram of included and excluded studies (Moher et al, 2015)
Data analysis
Qualitative data analysis through thematic indexing of
identified recruitment and retention factors was used. Items
were aggregated to provide an overall total number of factors
in each thematic group.
Results
The online search strategy retrieved 4864 records. Of these, 2138
duplicates were excluded, leaving 2726 articles, of which 2284
articles were then excluded after screening by title, leaving 442
articles, of which 374 were excluded after screening by abstract,
which were assessed for eligibility. Sixty-eight full-text studies
were screened, yielding 46 papers and a total sample size of 44 336
participants across the studies eligible for inclusion in this review.
No additional studies were identified from hand searching of
reference lists of included papers.
Individual study sample sizes ranged from 10 to 16 6707;
fewer than 10 had sample sizes of under 20, a similar number

The Quality Assessment Tool for Before-After (Pre-Post)
Studies with No Control Group (BAQA) was used to assess
the risk of bias of included studies (National Heart Lung and
Blood Institute, 2018). The exclusion of studies was not based
on the quality assessment score.
had sample sizes of thousands of participants, with the majority
(21) having sample sizes in the hundreds.
The included research studies were conducted across 14
countries. Twelve studies were performed in the USA, 12 in
Canada, six in Australia, four in the UK, two in Jordan and

British Journal of Nursing, 2021, Vol 30, No 5303

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Table 1. Factors influencing recruitment and retention

two in Japan. The following nations, Belgium, Iran, Lebanon,
Malawi, Malaysia, Portugal, South Africa and Taiwan contributed
Domain (subthemes) (cited by n studies) Number of times cited one study each.
Professional issues (n=22) Total n=45
Methodology quality assessment
■ Work-related stress and low job satisfaction, due to 23
All studies included in the review article clearly outlined their
burnout, high workloads, pressures, job demands/
perceived difficulties, emotional exhaustion objectives, study population and eligibility of participants.
■ Nursing skills out of date 3 Thirty-six articles were cross-sectional surveys and 10 were
■ Difficulty to find position that suits skills/experience 1 qualitative; three (Almada et al, 2004; McGillis Hall et al, 2011;
■ Working more hours (unpaid/involuntary overtime) 4 Schmiedeknecht et al, 2015) used mixed-methods approaches.
■ Low autonomy 9 All studies were rated as having a moderate risk of bias (25-
■ Advocating for patients 1 75%); none had a low risk of bias.
■ Quality of care provided 1
■ Translating skills 1 Outcomes
■ Communication issues 1 Most studies focused solely on retention factors and four
■ Job fit 1 investigated both recruitment and retention factors (Brewer et al,
2006; Bakker et al, 2010; Hart and Warren, 2015; McLemore et al,
Nursing leadership and management (n=22) Total n=34
2015).The individual items identified as influencing recruitment
■ Management and/leadership style: 10 and retention are presented in Table 1. Items were classified into
– Transformational leadership (positive) the following 10 domains:
– Abusive leadership (negative) ■ Professional factors
■ Managers listening to views 1
■ Nursing leadership and management
■ Lack of support from managers 13
■ Staffing issues
■ Lack of recognition/feel not valued 5
■ Education and career advancement aspects
■ Accessible leadership 1
■ Organisation and work environment issues
■ Managers engaged/visible in clinical environment 1
■ Support at work
■ Management/leadership incivility 2
■ Personal factors
■ Poor relationship with management 1
■ Demographic issues
Staffing issues (n=11) Total n=31 ■ Financial and monitory aspects
■ Unclassified influences.
■ High patient to nurse ratio 3
■ Low staffing levels 4
■ Staff shortages 12
Major factors identified
■ Better working conditions 1
Nursing leadership and management
■ Inflexible scheduling/working hours 9
The negative effects of poor management have been highlighted
■ Lack of ability to take breaks or time off 2 as deleterious features for staff nurse retention. Twenty-two
studies highlighted the influence of nursing leadership and
Education and career advancement opportunities (n=20) Total n=30 management on staffing levels within healthcare organisations.
■ Lack of continuing education opportunities 5 Lack of support from managers, and staff feeling not valued (not
■ Lack of staff development (training/knowledge and skills 11 recognised), followed by a negative management or leadership
advancement) style were the most common issues that had a negative effect on
■ Inability to innovate 1 nursing turnover. Bugajski and colleagues (2017) reported that of
■ Lack of career advancement opportunities (suppression 13 279 nurses who responded to their survey, more than 96% stated
of progress, lack of promotion opportunities, lack of that competent management and management that supported
opportunities for specialisation)
nurses were both very important factors. Nurses demonstrated
Organisational/work environment factors (n=16) Total n=24 dissatisfaction with a perceived lack of communication about
■ Organisational climate (oppressive work environment) 3
implemented organisational changes, and they experienced a
■ Team climate: lack of professional pride (physician 10 sense of powerlessness when major changes took place without
dominance) their invited input (Leurer et al, 2007). This is supported by
■ Poorly resourced workplaces 1 Valizadeh et al (2018), who observed that nurses:
■ Concerns about health and safety 2
■ Lack of empowerment (unable to participate in hospital 4 ‘Stated that lack of support by managers
affairs) and head nurse caused feelings of emptiness,
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■ Poor organisational rules 1 worthlessness and discouragement.’

■ Experienced verbal abuse 1
■ Dirty wards 1 Nurses also emphasised the significance of nurse leadership,
■ Violence at workplace 1 rather than management, as being the pre-eminent factor to
engage nurses and other staff in the creation of a supportive

304 British Journal of Nursing, 2021, Vol 30, No 5

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culture for quality improvement to enhance staff retention

Table 1. Factors influencing recruitment and retention (continued)
(Draper et al, 2008). Transformational leadership was seen to
promote organisational fairness, affective commitment, and Domain (subthemes) (cited by n studies) Number of times cited
high-quality care, in contrast to abusive leadership, which was Support at work (n=9) Total n=18
characterised by finding fault with staff, perpetuating a blame
■ Lack of support from peers (including allied health 10
culture, and a culture of inaccessible leaders and incivility
professionals)
(Lavoie-Tremblay et al, 2016;Van Osch et al, 2018).
■ Mentorship support 2
■ Positive orientation support/experience 3
Education and career advancement opportunities ■ Perceived supportiveness of the trust 2
Professional development and promotional opportunity aspects ■ Cynicism 1
were reported in 20 studies. Takase et al (2016) demonstrated
that the availability of advancement opportunities had a negative Personal factors (n=9) Total n=15
correlation with nursing turnover. In their study of 766 nurses, ■ Personal health issues 2
Takase and colleagues reported that the lack of opportunities for ■ Caring for family 2
promotion/professional development were cited as reasons by ■ Career changes 2
at least 39% of respondents to the survey. In a focus group of 56 ■ Loyalty 1
nurses (Brewer et al, 2006), the lack of professional development ■ Familiarity 1
opportunities was highlighted by many as a challenge for staff ■ Convenience 1
retention. Participants acknowledged that opportunities for ■ Maintaining work–life balance 3
continuing education—professional and academic—would ■ Job security 1
encourage the recruitment and retention of staff. ■ Desire to give back to community 1
Furthermore, participants stated that staff shortages, coupled ■ Lack of self-expression 1
with inflexible rota allocations, inevitably prevented nurses from Demographic factors (n=8) Total n=14
leaving the workplace to attend lectures. Within the current
economic climate, financial resources have also been identified ■ Level of education 4
as a strong limitation for some staff because employers do not ■ Age (generational differences and whether respondents 7
were nearing retirement, or were about to retire)
usually pay for continuing education (Brewer et al, 2006).
■ Gender 1
■ Work experience 2
Organisational factors
Many studies highlighted dimensions of the work environment Financial factors (n=10) Total n=13
as barriers to recruitment and retention: ■ Unsatisfactory salary (poor overtime pay, inadequate 13
■ Work climate/culture benefits)
■ A lack of teamwork and/or multidisciplinary collaboration
Unclassified influences (n=6) Total n=6
■ Poor working conditions
■ Availability of resources (including equipment, staff and ■ Political instability in the country where the nurses worked 1
infrastructure) ■ Crime 1
■ Lack of staff empowerment ■ Nepotism 1
■ Failure to promote/implement zero tolerance policies ■ Racism 1
towards violence against staff. ■ Affirmative action 1
A total of 24 organisational factors were reported in 16 ■ Discrimination 1
studies. Healthcare environments that advocated a greater
voice for nurses in decision-making, both at organisational and and the healthcare organisation overall. The theme of staffing
clinical levels to influence patient outcomes, had low turnover levels was closely linked to the professional factors identified
rates compared with those where staff were frustrated and in the studies, which included:
disillusioned due to a lack of empowerment (Brewer et al, 2006). ■ Staff experiencing low job satisfaction
Constant threats (and physical or emotional abuse) within an ■ High workload
already stressful environment had a negative effect on nurses’ job ■ Emotional exhaustion
satisfaction and morale. One of the studies (Barron et al, 2007) ■ High job pressure and demands
found that staff who experienced verbal abuse were 40% more ■ Work-related stress and frustration from being unable to
likely to leave their current employer and 28% more likely to perform professional duties to the best of their abilities.
leave the nursing profession altogether. Professional issues were reported in 22 studies. High
volumes of sick patients and long hours made it difficult
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Staffing levels and professional factors
Concerns about staffing levels were raised in 11 studies and
included low staffing levels, high patient-to-nurse ratios, staff
shortages, and the lack of opportunity to take breaks or time
off.These factors were found to affect both the individual nurse
for nurses to practise safely, with the consequence that this
affected the retention of experienced nurses. For organisations,
staff shortages threaten service capability, the quality of care,
and lead to inadequate and inequitable access to professional
development (Newman et al, 2002).

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‘Nurses who reported that they intend to leave
their current positions were significantly
more likely to have jobs with greater physical
and psychological demands, longer hours,
less autonomy and lower supervision and
peer support.’
Han et al, 2015
Other factors
The lack of peer support and lack of allied health professional
support was another retention concern, which was identified in
nine studies. Individual personal factors, such as health issues and
family matters, were also reported in nine studies; demographic
status (age, retirement, generational differences among staff,
gender and work experience) were identified as influencing
factors in eight studies and working terms and conditions,
including unsatisfactory salaries, were recorded in 10 studies.
Discussion
This study provides an up-to-date overview of the evidence
on barriers to the retention of nurses in hospital settings,
which include: poor nursing leadership and management,
lack of educational opportunities and career progression, the
organisational culture and environment, working terms and
conditions, demographic and personal challenges.The themes
observed in this review are recurrent and universal, and have
been a familiar refrain for decades in this long-standing nursing
shortage paradigm.Therefore, there is an urgent need to develop
and implement strategic policy and clinical practice responses
to the issue in order to:
■ Address the multifactorial consequences of the many
challenges identified
■ Undertake an overall review and impact assessment of the
strategies implemented previously to address the ongoing
challenges.
The main factors outlined in this study are strongly influenced
by the workplace culture within each individual healthcare
organisation. The literature reports that organisational culture
influences the workplace atmosphere, which influences nurses’
decision as to whether to stay in or leave their job (Hutchinson
et al, 2008). Traditional and current nursing leadership and
management structures are heavily hierarchical and this cultural
phenomenon affects the values, beliefs and behavioural patterns
of the nurses working within the organisation. Supportive
organisational cultures are key to the recruitment and retention
of staff (Kleinman, 2004, Leurer et al, 2007, Draper et al, 2008).
In some cases, due to poor leadership and lack of support,
nurses reported experiencing workplace bullying, leading to a
higher risk of burnout consequent to the stress imposed on staff
by the organisational environment (Unruh and Zhang 2013; Han
et al, 2015;Valizadeh et al, 2018).The events that occurred at Mid
Staffordshire Hospital, where 400-1200 potentially avoidable
patient deaths occurred due to poor management and poor care
over a 4-year period, are typical of a poor organisational culture
(Francis, 2013). The hospital had an insidious culture of fear,
bullying, a culture that tolerated poor standards, and that strongly
discouraged whistleblowing, all of which prevented staff from
306
doing their jobs to the best of their abilities and encouraged a
culture of secrecy, with management ignoring the concerns of
both staff and patients (Francis, 2013). Key issues highlighted
by the Frances inquiry included high staff turnover and the use
of agency or temporary staff. The events at Mid Staffordshire
illustrate why, for example, leadership and management issues,
and the hospital environment, can affect the recruitment and
retention of staff.These concerns were already being highlighted
20 years ago (Dunham and Klafehn, 1990) and are the same
issues that have been identified more recently (Buffington et
al, 2012; Unruh and Zhang, 2013; Han et al, 2015).
Lack of staff empowerment and a lack of support for staff
weakens nurses’ commitment to the organisation and reduces
job satisfaction.This results in major work-based problems, such
as loss of confidence, staff experiencing mental health issues
and depression, ultimately leading to reduced productivity, and
increased staff turnover (Spence Laschinger et al, 2009). Such
issues can lead to physical, mental and emotional exhaustion
due to these constant work pressures. Nurses who experience
burnout lose the motivation to work (Ramoo et al, 2013), which
not only results in reducing the quality of services provided,
but also causes nurses to be indifferent to their patients, which
again leads to high nurse turnover.
A focus on patient satisfaction through the delivery of high
quality care and service improvement is important, but emphasis
must also be placed on the management of human resources
through modification of organisational culture as a strategy to
attract and retain staff. A hospital working environment that
empowers and motivates nurses is a necessity for rejuvenating
and sustaining the nursing workforce, which is evidenced
by Magnet-accredited and Pathway to Excellence Program-
accredited hospitals. The Magnet-accreditation program and
the Pathway to Excellence accreditation program are overseen
by the American Nurses Credentialing Center and promote
the contribution of frontline nurses in influencing the practice
environment and, ultimately, enhancing patient outcomes
(Arthurs et al, 2018). These initiatives enhance and promote
interprofessional cooperation, ensure that staff contributions are
acknowledged and that there is communication with nurses at
all levels, involving them in the decision-making process.These
are some of the main ways that can help reduce staff turnover.
Therefore, it is important for nursing managers to create channels
through which staff can communicate easily with one another.
One example of this would be the introduction of ward- or
team-shared governance committees aimed at addressing local
clinical area concerns, as has been done at Nottingham University
Hospitals NHS Trust, where some of the authors work.
The development of new knowledge through research and
innovation, such as the clinical academic career pathway for
nurses, enhances career development pathways and is one of
the ways to attract and retain nursing talent.This is confirmed
in a study showing that the desire to establish a fulfilling career
© 2021 MA Healthcare Ltd
was the second most commonly reported reason that nurses
wanted to leave the profession (Philippou, 2015), with the need
for better remuneration being the main reason.This reinforces
the importance of focusing on nurses’ career development as a
staffing retention strategy.
British Journal of Nursing, 2021, Vol 30, No 5

Nurses who participated in the research reported in the
studies reviewed in this article described their struggles to
deliver the care that patients deserved in the context of wider
nursing, professional and staffing issues. Across the UK, the
safe staffing agenda takes high priority. A policy report by
the RCN (Helm and Bungeroth, 2017) found that 76% of
nurse leaders had concerns about ensuring safe staffing levels,
with 90% expressing concern about the recruitment of new
staff and 84% with the retention of existing staff (Helm and
Bungeroth, 2017). Current discourse calling for urgent action
to resolve the challenges facing the nursing profession highlights
that staff burnout, low morale and low job satisfaction are
prevalent and on the rise. Nursing as a profession is at risk of
becoming an unattractive career option and this would seem
to be reflected in the drop in the number of preregistration
nursing applicants to universities prior to 2018 (Beech at al,
2019). However, in the face of the current COVID-19 global
pandemic, UK universities received an overall 8.5% increase
in nursing applications compared with previous application
cycles (Universities and Colleges Admissions Service, 2021).
Box 1 outlines practical examples of the retention strategies
employed at one NHS trust in England.
Study strengths and limitations
The authors conducted a comprehensive search strategy with
strict adherence to PRISM guidelines (Moher et al, 2015).The
search strategy, data extraction and quality assessment were all
performed independently by the authors and consensus on the
findings was reached among the team. However, the review
focused on retention factors for hospital nurses only, limiting the
generalisability of findings to nurses working in other healthcare
settings.The authors noted that there was a limited number of
studies from developing countries and rural hospital settings.
Conclusion
Globally, healthcare institutions are striving to address nursing
shortages, a problem that has been heightened by the COVID-19
epidemic. Many of the identified factors that affect staff turnover
require immediate evidence-based co-operative strategies
between both employees and employers.
Nursing shortages inevitably have a direct impact on patient
safety and the quality of care, and the factors outlined in this
review place great emphasis on the need for hospitals and
policymakers to develop and implement better targeted and
relevant initiatives to address staff shortfalls. Although there is
an acknowledgement of the limited availability of some critical
resources such as finances, participants indicated that efforts
to improve organisational culture and the work environment
would foster greater collaborative relations among nurses, and
with managers and other health professionals, which, in turn,
would help increase their commitment to their jobs. Given
current workforce shortages, this review further highlights the
© 2021 MA Healthcare Ltd
need for continuous evaluation of the strategies employed in
healthcare organisations to address factors that pose barriers to
the recruitment and retention of nurses. BJN
Declaration of interest: none
British Journal of Nursing, 2021, Vol 30, No 5307
PROFESSIONAL
Box 1. Recruitment and retention strategies applied at
Nottingham University Hospitals NHS Trust
■ Identify factors that affect recruitment and retention at local
hospital level
■ Prioritise the implementation of key national workforce
strategies (public policies), for example, detailed workforce
measures from national documents such as the Interim NHS
People Plan (NHS England and NHS Improvement, 2019)
■ Identify other strategies that have been shown to positively
change retention and recruitment: for example:
– Developing and implementing staff empowerment and
autonomy strategies (shared governance councils) at ward,
divisional and other staff group levels. This empowers staff
to deal with and address local ward priorities to improve
staff and patient care outcomes
– Recruiting and sponsoring international nurses
– introducing return to practice and return to work after
retirement programmes
■ Evaluate implemented projects to identify and quantify their
impact, consider any further improvements required and
disseminate good practice. For example, the Chief Nurse
Excellence in Care Junior Fellowship initiative has been
evaluated and published demonstrating a successful impact
on professional development as a recruitment and retention
tool (Bramley et al, 2018)
■ Gaining international nursing recognition for world class
care; American Nurses Credentialing Center (ANCC) Magnet
accreditation and Pathway to Excellence accreditation
Acknowledgements: the authors would like to acknowledge
Dr Louise Bramley, Head of Nursing and Midwifery Research,
Institute for Nursing and Midwifery Care Excellence, Nottingham
University Hospitals NHS Trust, and Stephanie McHale,
Paediatric Critical Care Outreach Team Lead, Nottingham
Children’s Hospital, for their support during the review process
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KEY POINTS
■ Nursing shortages inevitably have a direct impact on patient safety and the
quality of care delivered
■ Turnover factors observed across studies have not changed over time
■ There is an urgent requirement to develop and implement strategic policy
and clinical practice responses to address high nurse turnover rates
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