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Keeping nurses nursing: a quantitative analysis

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VOL: 97, ISSUE: 07, PAGE NO: 35

Heather Gage, MSc, BSc, is senior lecturer, department of economics, University of Surrey, Guildford

Fiona Lake, MSc, was formerly research associate, department of economics;Rosemary Pope, PhD, BSc, RGN, RHV, is director of the Centre for Nursing and Midwifery Education, University of Surrey, Guildford

The shortage of nurses in the NHS is a recurrent problem that centres on the issues of recruitment, training, retention and return. Surveys show a consistent pattern of long-term nursing vacancies and ward closures in all regions and attempts by managers to address staffing shortfalls through foreign recruitment and increasing use of agency staff.

The shortage of nurses in the NHS is a recurrent problem that centres on the issues of recruitment, training, retention and return. Surveys show a consistent pattern of long-term nursing vacancies and ward closures in all regions and attempts by managers to address staffing shortfalls through foreign recruitment and increasing use of agency staff.

While recruitment is fundamental to the supply of nurses, it is also important to retain existing nurses and ensure that those taking a career break return to the profession. High wastage rates among trained staff adversely affect the skill balance in the profession and increase the rate at which new recruits must be enlisted (Audit Commission, 1997). Initial training is funded largely from the public purse and includes a bursary for trainees.

Qualitative evidence shows that a desire to join a caring profession is important in the career choice of would-be nurses (While and Blackman, 1998). But there is also evidence of significant disillusionment among the trained workforce, with between one-third and two-thirds of working nurses saying they would leave the profession if they could (Seccombe and Smith, 1997; Unison, 2000). The most frequently cited reasons for dissatisfaction are feeling undervalued, pay levels, working hours and conditions, lack of recognition and job stress.

The British Household Panel Survey
We undertook an analysis of the British Household Panel Survey (BHPS) in search of further evidence about the career decisions of qualified nurses that might inform the ongoing policy debate. Our study is unique in that it is based on a representative sample of the UK population and it covers both working nurses and people with nursing qualifications who were not employed as nurses at the time of the survey.

Unlike previous studies that investigate recruitment, retention and return through samples of current members of the workforce or by identifying leavers, the BHPS enables researchers to quantify attrition from the profession and study the characteristics of leavers in comparison with stayers. Because of its comprehensive coverage, it also allows us to explore whether trends observed in nursing are peculiar to that profession.

We selected teachers as a comparison because of similarities with nursing: both professions involve a three or four year university-based training that equips graduates with a vocational qualification for a career in a social service.

The BHPS offers researchers the possibility of examining labour markets in relation to a large number of social variables. Those of relevance to nursing retention include age, gender, marital status, dependent children, housing tenure, job satisfaction, overtime, second jobs and working hours. Moreover, the BHPS data set includes details of personal and household income so that individual level income comparisons can be drawn. Such analysis is rarely possible with studies based on primary data collection.

We investigated whether there were significant differences between people with nursing qualifications who were working as nurses and those with nursing qualifications who were not working as nurses (for whatever reason) with respect to socio-economic characteristics, conditions of employment and job satisfaction. We then compared patterns of leaving and staying in nursing and teaching. We also analysed data collected in the BHPS about the self-reported health status of respondents but, with the exception of smoking behaviour, we found little difference between the groups and these results are not reported here.

The data
The BHPS is an annual survey of over 10,000 adult members of a nationally representative sample of more than 5,000 households. The survey is conducted by the Economic and Social Research Council Research Centre on Micro-Social Change at the University of Essex. It is designed as a resource for a wide range of social science and interdisciplinary research.

Data is collected by interviewers and through self-completion questionnaires on a range of topics. We used six annual waves of the BHPS from 1991-1996, commencing in autumn 1991 when respondents were questioned about the period between September 1990 and August 1991. The second wave began in September 1992 covering the previous 12 months, and so on.

The sample core consisted of 6,419 individuals interviewed in every wave, thus creating a pure 'panel'. There was also movement into and out of the sample as new individuals joined the 'household' of existing sample members or as individuals were lost to follow-up.

This method yielded 242 people with nursing qualifications and 258 people with teaching qualifications. (For the full methodology of the report, refer to nursingtimes.net.)

The analysis we undertook was cross-sectional. Chi-square tests of association were used to compare stayers and leavers and to compare features of the nursing labour market with that of teaching. No attempt was made to statistically analyse movements in and out of the labour force because the numbers involved were too small.

Results of analysis
Quit rates

The job status of sample members with nursing and teaching qualifications is shown in Table 1. Although approximately the same proportion of nurses (14.5%) and teachers (15.1%) were not in employment, significantly more (p<0.01) sample="" members="" with="" teaching="" qualifications="" had="" left="" the="" teaching="" profession="" for="" other="" employment="" (38.8%)="" than="" qualified="" nurses="" had="" left="" nursing="" (28.1%).="">

Of the qualified nurses in non-nursing employment, 50% were working in related caring professions - especially social work, child care and dentistry. Of the qualified teachers in non-teaching employment, 20% had moved to higher education, but the remaining 80% were in a wide variety of occupations including managerial, technical, caring, service, clerical and skilled sectors.

Of those nurses not in employment, 83% were looking after their families and the rest were unemployed. Non-working sample members with nursing qualifications had significantly more children under 12 years of age than the working groups (p=0.10).

In comparison, one third of non-employed sample members with teaching qualifications had taken early retirement, a further third were full-time students, 20% were unemployed and the remaining 14% were involved in caring for their families.

There was no significant difference between the three groups of sample members with teaching qualifications with respect to dependent children.

Stayers and leavers

We compared the characteristics of sample members with nursing qualifications who were working as nurses with those who were working but not as nurses. Similarly, we compared working teachers with people with teaching qualifications who were working outside that profession. The results of these comparisons are shown in Table 2, columns 1-6. There were more significant differences between the two teacher groups (columns 4-6) than between the two nurses groups (columns 1-3).

Sample members who had left the nursing profession were older (p=0.004), less likely to be homeowners (p=0.04) and less likely to be working more than 30 hours per week (p=0.03) than sample members who remained as nurses. Working nurses were more likely to have a second job than those working in non-nursing jobs (p=0.05).

There was no significant difference between working nurses and those in non-nursing jobs with respect to gender, marital status, dependent children, overtime and smoking. Working nurses were less satisfied with their jobs than those who had left the profession (p<0.05).>

In contrast with the nursing sample, people with teaching qualifications who had left the teaching profession were significantly younger (p=0.007), more likely to be male (p=0.004), single (p=0.003), have a second paid job (p=0.09), work overtime (p=0.001), and be less satisfied with their job (p=0.09) than those staying in the profession. In common with the nursing sample, there was no significant difference between stayers and leavers with respect to dependent children; leavers were significantly more likely to be smokers (p=0.07) and renters (p=0.08) than stayers.

Nurses and teachers

Compared with teachers (Table 2, column 7), a significantly larger proportion of nurses were below 40 years of age (p<0.001), female=""><0.001), single=""><0.01), renters=""><0.001), in="" full-time="" work=""><0.001), undertaking="" overtime=""><0.001), not="" satisfied="" with="" their="" jobs=""><0.001) and="" smokers=""><0.01). there="" is="" greater="" variation="" in="" earnings="" between="" teacher="" groups="" than="" nurse="" groups="" and,="" on="" average,="" teachers="" have="" higher="" individual="" and="" household="" incomes="" than="" nurses.="" the="" household="" income="" of="" nurses="" not="" in="" the="" labour="" force="" is="" higher="" than="" that="" of="" non-working="" teachers="" (table="" 3).="">

Discussion

The BHPS data enable us to quantify the extent of the retention problems in the nursing profession and to compare them with teaching.

Twenty-eight per cent of those with nursing qualifications who were below retirement age and fit for work were working in other jobs. Half of these remained in caring professions but, on average, they earned less than nurses. In contrast, career shifts by qualified teachers are 10 percentage points higher than those of qualified nurses and 80% of teachers leaving the profession moved to very different occupations. People with teaching qualifications working outside their profession also earned, on average, less than working teachers.

The more pronounced gender imbalance in nursing may contribute to differences in quitting patterns. Women, 88% of the nursing sample compared with 68% in teaching, may be less mobile because of family responsibilities. They may not be able to consider jobs further from home or those that involve retraining or relocation. Significantly more male than female teachers left the profession and they tended to do so at younger ages.

Teachers may also leave in greater numbers because of a wider range of alternative career opportunities open to them. Nurses may have more specialised training which, coupled with a strong allegiance to a caring vocation, results in lower quit rates and a propensity for leavers to move into similar occupations. In contrast to teaching, attrition in nursing appears to occur disproportionately in older age groups.

Leavers from both the teaching and nursing professions are more likely to belong to the more mobile renting sector, rather than owning their own homes. Teachers who leave the profession are also significantly more likely to be single and smoke. Though not statistically significant, the trends for nurses point in the same direction. As a group, nurses smoke more than teachers.

The average income of working nurses in 1996 was £14,201 - about two-thirds that of teachers. In part the observed average income differences between the professions are accounted for by the younger age structure of the nursing sample and the fact that most teachers leaving teaching are in younger age groups. Even after allowing for differences in the age distribution, nursing pay scales are lower than those of teachers.

About the same proportions of working nurses (14.4%) and teachers (12.4%) have a second job, mostly in nursing and teaching respectively. More recent data from primary studies suggest that the proportion of nurses with second jobs has risen to around a quarter (While and Blackman, 1998; Seccombe and Smith, 1997). In line with other studies (Seccombe and Smith, 1996), the BHPS shows that more than half of nurses work overtime. The figure for teaching is 26%.

Leavers from the nursing profession earn, on average, slightly less than stayers, even though they tend to be older. There may be an element of self-selection: less able or disaffected nurses may not gain promotion and may leave for less responsible jobs outside the sector.

The problem of fitting family commitments around nurses' shift-work patterns is frequently cited as a reason underlying retention and return difficulties. Data on working hours in the BHPS (not reported here in detail) show significantly more variability and unsociability in nurses' schedules than in those reported by people who left the profession and by people in the teaching sample. Non-working nurses are significantly more likely to have children under 12 years of age than working nurses.

Furthermore, the BHPS data do not suggest that people in either profession with dependent children are more (or less) likely to leave their profession for other occupations. Accordingly, any family inconveniences created by inflexible working arrangements in nursing may be reflected mainly through reported job dissatisfaction and only at the margin result in exit.

When entering nursing, trainees are aware of the unsociable nature of shift-working. Indeed, this can work to the advantage of some women who can fit their own working arrangements around partners' free time to avoid child care expenses.

A third of the nursing workforce stated that they were not satisfied with their jobs. Fewer teachers express dissatisfaction. Would-be nurse leavers may be constrained by their commitment to their chosen profession, their family responsibilities and a lack of appropriate alternative opportunities.

Surveys of nurses point consistently to factors associated with the work environment as the prime cause for dissatisfaction, rather than to pay or personal circumstances. Sources of concern include excessive workloads, job-related stress, inadequate staff development and promotion opportunities, and adversarial supervisory arrangements (Cavanagh, 1992; Irvine and Evans, 1993). Such factors are within the control of local managers, and could have significant impact on morale and retention (Audit Commission, 1997).

Our data suggest that particular attention should be paid to more senior and experienced nurses in older age groups, where attrition rates are highest. This contrasts with recent policy announcements that have concentrated pay increases in lower grades for recently qualified nurses.

Conclusion
While many nurses leave the profession, wastage is lower than that of teaching. However, many more nurses than teachers express dissatisfaction with their jobs. Nurses may be less able to turn disaffection into a decision to change professions because of a lack of practical alternatives.

Government objectives to modernise the health service rely crucially on the contribution of a fully staffed and motivated nursing profession. Improvements in nursing work environments are needed to improve morale and retention and thereby increase the returns to society's investment in nurse training. Although the direct beneficiaries of such a strategy would be nurses and their families, all health service users stand to gain.

- The full version of this article is available at www.nursingtimes.net

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