Should I stay or Should I go? - Monitoring influences on NHS staff retention in the post COVID-19 world

Posted in: Culture and policy, Health, Public services, Science and research policy, Welfare and social security

Dr Andrew Weyman joined the University of Bath in 2006, having previously worked in central government.  His specialism is the psychology of risk, in particular employee safety, health and well-being at work. A central theme of his more recent research has been the issue of staff retention. He was principal investor for Should I stay or Should I go? - Monitoring influences on NHS staff retention in the post COVID-19 world (ESRC 2020-22); Extending working life – Audit of research relating to impacts on NHS Employees (NHS Employers 2013); Extending working life – Behaviour change interventions (DWP 2012-2013) and co-investigation for Extending Working Lives in the NHS: Opportunities, Challenges and Prospects (MRC 2014-2018) and Extending Working Life Uncertain futures, Late Career Transitions (ESRC 2014-2017).

The issue of staff retention in the NHS is not new but has been brought into sharp relief in the post-COVID-19 era of unpreceded staff shortage.  While steps have been taken to train new health professionals and recruit from overseas, net gains to the NHS staff complement are at risk of being significantly blunted or defeated in the absence of finding ways to stabilise and enhance the retention of established staff.  

At the institutional level, what has been widely characterised as a pandemic of early-exit risks a spiral of inter-related losses becoming endemic. Foreseeable impacts include loss of expertise and institutional memory, degraded capacity to deliver patient care, degraded workforce and work-team stability, loss of return on investment in health professional training, and increased human resource costs to employers (e.g. recruitment and employment of bank/agency staff). All have implications for standards of patient care and the potential to negatively impact on the well-being of staff in-post to the extent that it risks degrading their disposition and/or capacity to remain.

Should I stay or should I go? NHS staff retention in the post COVID-19 world: Challenges and prospects’, was funded by the Economic and Social Research Council, in response to the UKRI open-call for COVID-19 relevant social research in spring 2020 and has received follow-on funding from the health sector.

The study took a risk management and mitigation systems perspective to explore variables with potential impact on staff well-being, in particular their disposition to stay or leave NHS employment. This was a mixed methods study that aimed to tap the insights of NHS employees (all professions/occupations, grades) working in secondary care (acute hospitals, mental health, community and ambulance services) as well as in non-provider roles.

The study comprised of a four-wave staff survey covering the period winter 2020 to spring 2023) and interviews with a cross section of employees (2021-2022).

The study was design to provide human resource strategy and policy relevant insight into:

  • The impact of the COVID-19 experiences and its legacy on employees’ strength of attachment, commitment and capacity to remain in NHS employment;
  • The relative salience and strength of push and pull variables on staff stay versus leave intentions and behaviour;
  • What might need to change to motivate/enable current employees to remain in NHS employment; and  
  • The need, nature and scope for intervention to maintain/enhance retention rates.

At Wave four of our survey, the scope of data gathering broadened from its initial focus on primary impacts arising from COVID-19 in 2020/21 to include other features of the post- pandemic work environment, including: staff shortages, workload, job-demands, working conditions, pay and other background climate factors on staff resilience, capacity and disposition to remain.

The most prominent and salient finding from the four waves of data gathering was that, while impacts on staff well-being and disposition to remain in NHS employment directly attributable to the COVID-19 pandemic have attenuated, the core feature of insufficient institutional capacity to meet the demand for care persists. This presents as the biggest single root cause and challenge to staff resilience.

Perhaps the most striking finding was the 24 percentage point drop from 61% to 37% in the proportion of staff who ‘would recommend working for the NHS to others’ between winter 2020/21 and spring 2023.

By Wave Four of the survey there was an indication of some stabilisation in previously rising profile of rates of staff applying for jobs outside the NHS. However, the (all-staff) external (non-NHS employment) application rate remains quite high at around one in seven employees, and one in four for certain segments, notably early career staff and ambulance service personnel. There were also continued more negative moves that are precursors to external applications.

The majority of variables explored showed either no change, or rising negative trajectories, i.e. ratings of an array of fundamental issues have become more negative between 2020 and 2023, year on year. Their persistence in the context of falling demand for COVID-19 care is suggestive of deeply rooted issues, that do not present as transitory consequences of the unprecedented demands on staff at the height of the pandemic, or issues that are solely attributable to the pandemic and its legacy.  

This suggests that either the increasingly negative profile of these variables was present and incubating prior to the emergence of COVID-19, although plausibly becoming more visible because of the pandemic, or that negative changes to working conditions/arrangements that emerged in response to the pandemic have become baked-in features of the new-normal of the post-pandemic workplace climate. It is possible, perhaps likely, that elements of both may be at play.  

In spring 2023, around two in three respondents rated staffing levels, workload and feeling undervalued by government as having worsened over the previous six months, a rise from about one in two in spring 2022. In 2023, one in two reported a worsening of morale or stress, confirming the rising linear profile indicated in previous waves. Mirroring findings at Wave Three, ratings of confidence that working conditions would improve over the next 12 months (i.e. from spring 2023) ranged from low (e.g. workload, NHS funding) to modest (e.g. delivering acceptable care) across each of the criteria explored.

Over half of respondents reported tiredness and one in three low-energy (every day or on most days). Approximately one in four reported physical exhaustion, mental exhaustion and feeling overwhelmed in spring 2023. All burnout measures assessed had worsened relative to Wave three.  By inference, this has intuitive implications for staff productivity.

The most commonly cited reasons why staff leave NHS employment in spring 2023 were, respectively, stress, workload, shortage of staff/resources and pay. The first three reflect close alignment with their profiles in previous waves. A notable change since 2020, however, was the ascendant profile of pay; ranked eighth of the 15 variables explored in winter 2020/21, rising to fourth in spring 2023.

Contemporary perspectives on staff retention, and consideration of what might need to change to stabilise/enhance retention invariably focus on determining why staff leave. However, a focus on pushvariables alone risks producing a partial perspective. It is also important to consider the role of pull variables, i.e. those factors that underpin why staff continue in their current employment. Insight into both push and pullvariables is necessary to produce a comprehensive perspective on what might need to be preserved, emphasised, or enhanced to support staff well-being and mitigate exit rates.

Our findings indicate not only negative changes in the profile of push variables, but also a trend of weakening headline pull influences, notably with respect to job security and intrinsic elements relating to job satisfaction from caring for patients and personal commitment to the NHS. Relatedly, the negative profile of ratings of working conditions, concern over standards of patient care, and insufficient time to do their job properly supports the inference that the arising impacts conspire to frustrate the primary motivation of a significant proportion of NHS care providers.  

All articles posted on this blog give the views of the author(s), and not the position of the IPR, nor of the University of Bath.

Read the report ‘Should I stay or Should I go? – 2 Monitoring influences on NHS staff retention in the post COVID-19 world. Winter 2020 to Spring 2023’.



Posted in: Culture and policy, Health, Public services, Science and research policy, Welfare and social security


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