Abstract
There are over 41 000 vacant nursing posts across the United Kingdom’s National Health Service (NHS), with more people leaving the profession that joining it. Despite mental health being acknowledged as a priority area, some of the most significant staff shortages are occurring within mental health services. Urgent action is needed to retain the mental health nurses (MHNs) currently in post to ensure the profession is fit for purpose and aid future recruitment efforts. This review set out to identify the individual factors that affect the retention of MHNs. A systematic search of six databases was conducted (CINAHL, PsychINFO, MEDLINE, Web of Science (Core collection), EMBASE and the British Nursing Index). Studies were systematically screened for inclusion based on predetermined eligibility criteria. The studies were quality assessed using the Mixed Methods Appraisal Tool (MMAT). Findings were synthesized using Thematic Synthesis. A total of 23 studies consisting of a range of study designs were included in the review. Four key themes emerged from the synthesis: Individual characteristics, Working within mental health services, Training and skills and Work environment. The findings from this review suggest that MHNs encounter some factors unique to working in mental health services, which suggests that retention strategies should be specific to each nursing speciality. Beyond nursing speciality, the factors identified vary between clinical settings in mental health due to the differences in work environments and services they provide. Future studies should now set out to explore what factors exist in which clinical settings to inform better tailored retention strategies to generate better outcomes.
Background
Nursing shortages represent a global concern, with the World Health Organization (2013) estimating a 12.9 million deficit in skilled health professionals made up of physicians, nurses and midwives by 2035. The most significant shortages are currently occurring in Africa and South-East Asia (World Health Organization 2020), whilst future nursing workforces in the UK, United States, Australia and Portugal are vulnerable to significant projected shortages from an ageing workforce and limited workforce planning policies (Buchan et al. 2015). Nurses make up 50% of the global healthcare workforce (World Health Organization 2020) and account for over a quarter of the UK’s NHS staff (Beech et al. 2019). With increasing demand, insufficient resources and deteriorating job satisfaction, the NHS nursing workforce is overstretched and depleting rapidly, now accounting for 40% of staff shortages in hospital, community and mental health services (Beech et al. 2019). There are currently over 41,000 vacant nursing posts within the NHS (Buchan et al. 2019), with more people currently leaving the profession than joining it (Nursing & Midwifery Council 2017). Despite efforts to increase the number of nurses being trained, there was a decline in the numbers of nursing applications for nurse training in England in 2017 and 2018 (Buchan et al. 2019).
Mental health is a priority area identified within the ‘NHS long-term plan’, ‘interim NHS people plan’ and ‘five-year forward view’, yet the most significant staff shortages are occurring within the NHS mental health nursing workforce. Years of underinvestment and funding cuts to mental health services, nurses pay and training bursaries have given rise to these staff shortages (Unison 2017a), evidenced by a drastic 12% fall in MHNs between 2010 and 2017 in the NHS (Care Quality Commission 2017). Even with increased efforts to recruit and retain MHNs, their numbers rose by <0.5% in 2018 (Buchan et al. 2019). Due to poor retention and high turnover, a National Retention Programme (NRP) was launched in 2017 by the NHS. Under this scheme, clinical mental health staff turnover has decreased from 14.3% to 13.4%, but there is still a long way to go to resolve this current crisis (NHS Improvement 2019a). Poor retention reduces the ability of MHNs to meet service user’s needs leading to dangerous consequences for service user care and safety (Unison 2017a) and is likely to deter people from wanting to join the profession.
Developing strategies focused on encouraging recruitment may be a futile occupation if retention is not addressed. Whilst nurse turnover can be beneficial by bringing in new perspectives, ideas and experience, high turnover rates often come with high economic and non-economic costs (Dewanto & Wardhani 2018). Instability of nursing staff leads to unstable nursing care, which increases the risk of care and treatment errors that can have grave effects of patient care and safety (O’Brien-Pallas et al. 2010), whereas relying on bank and agency staff, continuous recruitment and orientation and training processes constitutes a large economic burden (Jones & Gates 2007). In 2018, the NHS had reportedly spent £353 million on agency and bank staff to meet safe staffing requirements (Buchan et al. 2019). Urgent action is required to reverse this trend and reduce the use of bank and agency nurses (Royal College of Nursing 2015), before patient safety is put at greater risk (Unison 2017b). More immediate emphasis should be placed on retaining the staff already in post. By doing this, we can help to ensure the current profession is fit for purpose, and one that others aspire to join to aid retention and boost recruitment (Unison 2017b).
Job dissatisfaction appears to be strongly associated with poor retention (Happell 2008; Health Education England 2014; Ward 2011). Job satisfaction for MHNs is reportedly the lowest it has ever been, with many nurses emotionally and physically exhausted, leading them to consider leaving their profession (Unison 2017b). This results in a negative cycle where the consequences of poor job satisfaction and turnover, for example increased workload, pressure and working with temporary or inadequate numbers of MHNs, lead to even more turnover (Jones & Gates 2007). Recent events have seen us delve into the depths of a global pandemic which has now placed even more pressure on the mental health workforce, due to increasing demand and even more staff shortages as a result of shielding, sickness and self-isolation guidance (British Medical Association 2020). The additional pressures of the pandemic are likely to result in an exacerbation of the already significant international nurse shortages (Turale & Nantsupawat 2021).
Much of the literature surrounding nurse turnover and retention is for adult nursing (Chan et al. 2013; Halter et al. 2017; Moseley et al. 2008). Whilst there is some research focused on MHN retention, there has not yet been a systematic review consolidating the evidence on factors that affect retention within this workforce. With the concerning consequences of poor retention on patient care and safety, it is imperative to get a better understanding of the specific factors causing MHNs to leave or contemplating leaving; so that meaningful and targeted retention strategies can be put in place to resolve this current crisis. The aim of this review is to identify what factors affect the retention of MHNs, in order to inform retention strategies and identify areas for future research.
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