Abstracts

A realist review of factors affecting retention of mental health staff in UK adult services

Background

The staffing and retention crisis in the NHS is well documented. Mental health Trusts have, on average, more vacancies and higher turnover than other NHS organisations. The aim of this work is to identify and map the literature related to factors at an organisation, management and frontline level that influence retention and turnover of the mental healthcare workforce in the UK.

Methods

Factors effecting retention of the mental healthcare workforce are likely to be complex, involving various people, structures and policies at an organisation, management and frontline level any retention interventions effectiveness is likely to be contingent upon a variety of factors. The study used a realist approach, which could accommodate such complexity and interconnectivity, to develop a theoretical understanding of what factors influence clinical workforce retention within UK mental healthcare. Scoping and stakeholder work suggested six initial programme theories, workload, quality of care, team cohesion, leadership, developing and supervision. Separate searches were carried out for each of these.

Results

88 papers were included: Workload: 26; Quality of Care: 37; Team Cohesion: 41; Leadership: 13; Development: 36; Supervision: 27. Some papers contributed to more than one programme theory. After analysis three modified programme theories were central to our understanding of retention in mental health services. 1. The interconnectedness of workload and quality of care, 2. Investment in staff support and development and 3. Clinically led policies and practices.

Implications

The loss of staff is hugely detrimental to the NHS both in terms of patient care, patient and carer outcomes and financial cost. Lessons learned from this research should result in identified actions to improve retention rates, improving patient outcomes and reducing the costs to the NHS. Although this study is aimed at retention in mental health services it is anticipated that it will be more widely applicable, both to wider health sectors nationally and internationally. It is also anticipated that this work will have an impact on workforce well-being as well as retention – another costly area for health services in terms of productivity lost via sickness absence.

Predictors of Staff Turnover in NHS Mental Health Trusts

Background

In 2013 the RN4CAST study reported that 43% of nurses intended to change jobs within the next year; in 2021 there were an estimated 93,000 vacancies in the NHS in England. Healthcare staff leaving jobs is causing problems for health services, and mental health trusts are particularly badly hit, with both higher turnover rates than other parts of the NHS, and higher vacancy rates. Therefore this study examined predictors of staff turnover in NHS mental health trusts, using data from NHS staff and patient surveys and staff absence as primary predictors.

Methods

Annual data on staff turnover (stability index) for all 57 mental health trusts in England were collected from NHS Digital for 2015 to 2019. This was matched with data from each trust in the same years on (a) staff experience (NHS staff survey), (b) patient satisfaction (community mental health service user survey), and (c) staff sickness absence, published by NHS Digital. Two summary indicators (staff engagement and staff satisfaction) were used for the staff survey, and one for patient satisfaction.

Analysis included regression with turnover in 2018/19 predicted by staff satisfaction and engagement, patient satisfaction and staff absence, controlling for trust type, region, location, and CQC ratings. This was repeated controlling for with prior turnover as well. Growth curve analysis was used to examine whether changes in turnover over time were predicted by these factors.

Results

Regression revealed that only staff absence (B = 0.010, p = .020) and region (B = 0.023, p = .023) were significant predictors of staff turnover. With all else equal, a 1% rise in staff absence is associated with 1% higher staff turnover, and trusts in London have 2.3% higher turnover than others. When controlling for previous year’s turnover, no other predictors were statistically significant. Sensitivity analysis using different years’ data revealed similar patterns.

Growth curve models failed to converge, so no results could be found. This is likely due to the small sample size (50 organisations with data across the four years), and the relative volatility of some of the variables.

Implications

The lack of links between staff/patient experience and turnover is likely due in part to a small sample of organisations leading to low statistical power. Given all the mental health trusts in England were included, this is a systemic problem. It is recommended that future work collects data from smaller units to allow a larger sample size.

Understanding factors affecting mental health workforce retention using organisational case studies

Background

The NHS is struggling to retain clinical staff across all sectors, with an average of 15% of NHS staff leaving their job every year. These problems are particularly acute within mental health, which has the highest turnover of all sectors. However, turnover in mental health trusts varies significantly across the UK, ranging from 9% to 38%. Understanding this variation between mental health trusts is key to identifying and better recognising the reasons staff stay in or leave their job, and can inform the development of appropriate interventions to address these issues. This research is part of a multi staged research project looking at better understanding how organisational contexts and the experiences of health care staff in the workplace influence staff retention and patient outcomes.

Method

We used organisational case studies to explore the effects of, and interactions between, the Trust management, national influences, staff characteristics, roles, workplace practices and experiences at work. Six NHS Trusts in England with different retention rates across the UK were identified, based on the following factors: staff turnover; CQC rating; staff satisfaction on the NHS staff survey; and location. Clinical staff (band 5 and above, including nurses, OTs, psychiatrists, psychologists in both community and inpatient settings) who held a professional registration were invited to interview via offsite recruitment methods such as all-staff email. Key strategic senior staff were also selectively approached and invited to interview. Due to the restrictions imposed by COVID, all interviews were carried out remotely, either via online platforms or by telephone. In total 197 qualitative semi-structured interviews with key stakeholders were completed, including 169 frontline clinical staff and 28 senior staff. Data is currently being analysed using framework analysis informed by initial programme theories developed in a realist review by the same research team, and by emerging themes derived from the interview data.

Results

Analysis is currently ongoing; the results will be shared for the first time at this conference.

Implications

The key findings from these organisational case studies will enable identification of key policies and practice which have a positive impact on clinical staff retention and inform recommendations to improve staff retention across the NHS. Improving staff retention and satisfaction not only benefits the individuals, but also service-users, who have repeatedly emphasised the importance of continuity of care and therapeutic benefits of established relationships with staff. It also benefits employing organisations, who retain experienced, well-trained staff and reduce their recruitment, induction and training costs.

Virtual data collection - experiences of participants and interviewers

Background

Historically qualitative data collection has generally been assumed to require face-to-face contact, or at least to be significantly enhanced by this. However, the arrival of COVID-19 and the consequent social distancing has required researchers to rethink and adapt their strategies.

The Retention of Mental Health Staff (ROMHS) research study aims to understand the factors affecting the retention of clinical staff within mental health trusts in the UK. A major part of the project is a multiple case study, involving interviews with senior and frontline clinical staff in six trusts across England. The intention was for the researchers to travel to the Trusts and recruit staff through direct contacts at their workplaces e.g. hospitals, outpatient clinics etc, and to conduct ethnographically-informed observations e.g. attending meetings where relevant issues were being discussed. However, the timing of data collection (April - October 2021) coincided with a significant level of COVID restrictions, and with NHS Trusts’ limiting unnecessary external contact which could affect the health of both staff and patients. As a result, the research team made a decision to move to online data collection, and to review this as the project progressed.

Methods

The research team liaised with each NHS Trust’s R&D team to identify appropriate recruitment strategies to ensure as wide a reach of clinical staff as possible, including people with a range of job roles and perspectives. Senior staff with responsibility for Trust policy around retention were also approached. Potential participants were invited to complete an online consent form with their contact details, which came directly to the research team. The team then made contact to ensure eligibility and arrange an interview by telephone or online. Interviews used a semi-structured format and were audio recorded for later transcription. At the end of the interview, participants were asked about their experience of taking part in virtual data collection, and any benefits or drawbacks they could identify. The responses to these questions are being coded and analysed separately.

Results

In total, 197 interviews were conducted, including 169 with frontline clinical staff and 28 with senior staff. Interviews lasted an average of approximately 47 minutes (range 24-83 minutes). Most were conducted online rather than telephone. There were some difficulties in setting up online interviews due to use of differing systems between the organisations. Sound and connectivity quality was variable, and in some instances created significant problems, including for transcribers, so interviewers wrote detailed notes to act as an aide memoire.

Participants were generally positive about the experience of participating virtually, highlighting the convenience and greater confidentiality it offered. Many staff were working from home due to COVID, whilst others chose to do the interview in their non-working time, and valued being able to slot the interview into their very pressured lives, as well as appreciating the privacy that this situation offered. Some areas of concern included lack of ability to see the workplace environment and the potential to exclude those who were less technologically confident. For the research team, virtual interviewing provided significant savings in time and cost, as well as reducing infection risk and isolation due to working away from home. Further findings will be presented when analysis is complete.

Implications

Virtual interviewing offers a potentially viable alternative to face-to-face data collection, with significant benefits in terms of resource savings. However, the potential loss of contextual data and exclusion of less technologically-confident participants needs to be carefully considered.