“If we are serious about nurse retention we must nurture and support our staff”

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(Left to Right: Jane Wray; Helen Gibson; David Barrett; Judy Brook; Rosie Stenhouse)

At this year’s Royal College At this year’s Royal College of Nursing (RCN) International Nursing Conference and Exhibition 2019 (Sheffield Hallam University, 3-5 September), the STaR project team were delighted to share our preliminary findings with an international audience of nursing academics, practitioners and researchers.

Jane Wray hosted a symposium of four papers on “Retention of newly qualified nurses (NQNs) in the UK National Health Service (NHS) on the 2nd day of the conference. David Barrett presented the findings from the STaR project Rapid Evidence Review, and this was followed by Jane and Helen Gibson (STaR project post-doctoral researcher) on the interview data “Perspectives on support during the transition from student to NQN: Views of students, NQNs, academics and clinical managers”. The third paper was by Dr Rosie Stenhouse (The University of Edinburgh) on “Job Embeddedness: Towards a Theory of Retention in Newly Qualified Nurses/Midwives” and she presented findings from interviews with 23 early career nurses about their experience of the workplace. This work is part of a larger longitudinal study exploring engagement levels, emotional intelligence, resilience and burnout yearly, retention, academic grade and following qualification, pay.  The final one was by Analisa Smythe (Birmingham and Solihull Mental Health NHS Foundation Trust) on “A qualitative study of experiences of online peer support for NQNs” – a project also funded by the Burdett Trust for Nursing that used focus groups with NQNs to refine an online peer support intervention.

There was lots of interesting comments and questions and it was great to hear from recently qualified nurses in the audience whose experiences appear to be very similar to the ones we reported – further validating our findings. The wider discussion at the end of the symposium focused on workforce and retention and the key message was that if organisations want to attract and retain staff they need to ensure that all staff (not just NQNs) are given the ‘the right support, at the right time and in the right place’ and that ‘if we are serious about nurse retention we must nurture and support our staff’.

Throughout the conference workforce issues including safe staffing, staff shortages and retention were repeatedly referred to. We also attended a symposium led by Judy Brook (City University) on “Development and implementation of an intervention to increase retention and decrease burnout of early career nurses” – another project supported by the Burdett Trust for Nursing.  It was interesting to see how coproduction is being used to develop an intervention to support transition. This team have published a systematic review related to their project and you can find out further information about their work by contacting JudyBrook (judy.brook@city.ac.uk).

Supporting Transition and Retention of newly qualified nurses

shaz2Sharon Aldridge-Bent

The General Practice Nursing 10 Point Plan (GPN 10PP)  has given an investment of £15 million from the General Practice Forward View (GPFV) funding allocation, to support action which will address the significant workforce challenges and support improvements in General Practice nursing (GPN) by 2020.

The Queen’s Nursing Institute (QNI) has been commissioned by NHS England to develop an Induction Template specifically designed to enable employers to ensure that nurses in a first career destination role in General Practice are well supported when taking their first career step in primary care.

As a programme manager at the QNI, one aspect of my role has been to develop and write transition resources, such as Transition to District Nursing and more recently Care Home Nursing, which I had found relatively straightforward, as in my previous role as a senior lecturer in a university I had taught widely in these aspects of nursing.

I was less familiar with general practice nursing and in particular the orientation and induction of nurses into this discipline and, initially, I did wonder whether I was the right person to write this document.   As the work continued, I began to realise that my ignorance was an advantage, as I came with absolutely no preconceived ideas about the discipline and took a neutral approach to the evidence I collected. I scrutinised and analysed every aspect of the template with a new and fresh approach to how newly qualified nurses would approach this area of nursing.

The QNI has a systematic approach to this type of work, which involves gathering evidence from a wide range of perspectives. I set about the process with an extensive literature search of the subject matter. This search reaped some good quality and relevant studies, as well as several induction templates that had been performed in the same or similar settings.

I then developed a questionnaire that was circulated via Survey Monkey to our networks, requesting insight and input into what the challenges were around orientation and induction into general practice. It was important that this questionnaire went to all stakeholders that were to be represented within the template, e.g. student nurses, nurses thinking about moving into general practice, existing general practice nurses, employers, including GPs and Practice Managers, and Higher Education Institutions. The response was tremendous and this assisted me when formulating my ideas around the format of the template.

I then set about developing an external review group that would represent all perspectives of this work and I also took advice from NHSE colleagues regarding relevant participants. The review group consisted of representatives such as student nurse groups, general practice nurses, GPs and Practice Managers, as well as input from Health Education England, The Royal College of Nursing GPN Forum, Care Quality Commission, several universities and colleagues at the QNI. I visited all the regional delivery boards of the GPN 10PP to update widely on this work and undertook telephone interviews with the external reviewers. I also attended the newly formed Association of Academic General Practice Nurse Educators (AAGPNE) to get an understanding of how academic programmes for GPNs were being developed.

Upon drafting a first plan of the work, I chaired a small focus group of six general practice nurses where the document was scrutinised for accuracy and to ensure that there were no fundamental omissions. The external review panel were then sent the second draft for feedback before final edits and publication.

My personal reflection of developing this template was I felt very privileged to meet such committed and experienced nurses who had developed professionally, despite (at times) lack of acknowledgement and professional identity of other nurses working in adjacent specialities in the community setting. I was struck by how complex the role of the general practice nurse was and how it most definitely would appeal to newly qualified nurses, because all the knowledge and skills attained as a pre-registration nurse can be utilised in this role. Also, to add that:

‘Developing this template highlighted the urgent need for a comprehensive induction and orientation programme for all nurses new to general practice. This most certainly will assist with recruitment and retention of nurses in the primary care setting’.

The document is hosted on the GPN Single Point website. Click here to view the document (you will need to request access here.). The document can also be viewed on the QNI’s website.

Sharon Aldridge-Bent

Programme Manager, The Queen’s Nursing Institute

Email: sharon.aldridge-bent@qni.org.uk

Twitter: @saldri01

The role of clinical educators in supporting newly qualified nurses during transition

Bill Whitehead 30 June 2019

Bill-Whitehead-(3I’ve been interested in supporting newly qualified nurses (NQNs) during their transition from student to staff nurse since I first qualified in 1990.  It seemed obvious to me then that the provision of clinical educators in practice to support students should also be there to support NQNs.  I had learned a lot during my traditional three year apprenticeship but I hadn’t realised the full range of skills needed in the specialist area of acute medicine that I landed in.  These included an understanding of all the roles of the multi-disciplinary team, the treatment and care of patients with the specialist conditions on the ward and most importantly, an understanding of the social care required for the mainly elderly and often newly infirm patients on discharge.  This took me a while to learn and there were times when I thought it was beyond.  As a newly qualified former mature student, I knew that really what I needed was the time and support to learn.  Consequently, I started looking into the theory and evidence around NQN transition nearly thirty years ago.

The transition from student to registered nurse has long been known to be a difficult time for NQNs joining the register.  Marlene Kramer made this the subject of her PhD thesis in the 1960s and published her seminal book “Reality Shock: Why Nurses Leave Nursing” in the 1970s.  The main finding of her research, over fifty years ago, was that NQNs were less likely to leave early in their career if they had a supportive programme linking their time as a student to registrant to support the transition.  In the twenty-first century we have developed this supportive programme into preceptorship support programmes.  These are usually run entirely by the employer of the NQN but as Kramer found in what she described as the “anticipatory socialisation programme” the support for transition works best if it starts during the pre-registration education programme.  Where this can run seamlessly into local employers’ preceptorship programmes the transition shock for NQNs is understandably reduced to more manageable levels.  There has been plenty of research in the intervening half a century since Kramer’s work and at least two systematic reviews of these research projects in the last few years to support the need for a period of good supported transition arrangements.  The latest research includes Health Education England’s recent RePAIR project and the ongoing STAR project.

I’m the general secretary of the UK Clinical Nurse Educator Network (CNEnet). The network was set up to link up and share good practice between CNEs.  I co-founded this organisation with Liz Allibone because we had both done this job and both, separately, completed research which indicated the need for it.  One of the central roles of CNEs is supporting the transition of NQNs.  We know this from our own experience and from a recent survey of members which indicated that over 90% had a role in supporting NQNs and believed that it encourages NQNs to join their organisation and to stay with them.  Our research indicated that for best results an organisations preceptorship programme needs to provide three levels of support:

  1. A named more experienced registrant in their team as a preceptor
  2. A supportive team who recognise the need for NQNs to have time and support to learn the ropes
  3. An organisational level support programme ideally linked to local pre-registration programmes to provide a feeling of seamless supportive environment for the senior student transitioning into an NQN

This all needs dedicated staff to organise and sustain.  Therefore, the clinical nurse educator is not an “expensive luxury”, as some employers have believed in the past, but a “practical necessity”.  Without them, as Kramer proved fifty years ago, “nurses leave nursing” too early in their careers.

Could you add this to the bottom – For more information about the Clinical Nurse Educators Network see this link.

The Royal College of Nursing Congress 2019 – ACC Liverpool by Jane Wray

This year’s Congress took place between the 19 – 23 May and as always had a packed agenda with debates on a range of professional, clinical, educational and practice issues in addition to the exhibition and fringe events. Professor Anne Marie Rafferty—President of the RCN Council opened her first Congress with a rousing speech encouraging nurses and nursing to find their voice and stand up and speak out about matters that effect the profession.  Issues affecting the nursing workforce and especially safe staffing was a dominant theme throughout and I was particularly delighted to attend the session on ‘Transition from student to newly qualified nurse’ led by the RCN Newly Qualified Nurses Network which launched in December 2010 by Charlotte Hall. I attended with my STaR project hat on – and it was really inspiring to hear the NQNs stories from all the different branches of nursing and the wealth of advice students and NQNs shared with each other. Some really useful discussions:

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Don’t Panic and Talk to Others – emphasizing the importance of both formal and informal support during the first 6-12 months. Talking with others, your peers, your friends, your family as well as your colleagues and preceptor.

Ask questions of your preceptor and team ‘How are you going to support me during this transition period?’ This is the period of time in which the team / your preceptor invest in you as a NQN. What does your preceptorship period look like? How long are you supernumerary for? What about your induction period? What happens after induction?

Accept that you are still learning – When you first staff you sometimes feel like you should know everything but just accept that you cannot know everything and you never will. Nursing is in almost constant change and you will keep learning not just in your first year of practice but throughout your career.

You can change your mind! – it is important to build trusting relationships with those that you work with but always remember that if this isn’t working for you – you can change your mind and choose to work elsewhere.

Finally it was really great to hear NQNs challenging the myth that you couldn’t work as a GPN as your first destination post and also how students and NQNs are ‘defenders’ of degree level education for nursing.

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Photo: Charlotte Hall and the RCN Newly Qualified Nurses Network open the discussion on transition

Almost 5 months as an NQN! by newly qualified nurse Dan Gooding

I have now been qualified for slightly less than 5 months. In that time, I have learnt some hard and fast lesson about being a PICU Nurse. I have been apart of successful & unsuccessful arrests, I have made mistakes and owned up about it, which is super scary. Essentially, I realise that I am a really really junior nurse. But, a nurse I am, and gaining experience each shift I am doing.

What I have learnt is it takes time putting theory into practice. I am not as smart as people seem to think I am. Being dyslexic, I feel like I have to work hard! And I really worry when I struggle to learn something. But something I am realising now is that the first several months of being an NQN can feel like getting into a routine, and learning what to do in a situation. What as opposed to why. This stressed me out, because I like to know why, I like to have understanding, because knowledge is power. And not knowing is pants!

But now, finally, on occasion, I am starting to believe that I could be a half decent nurse. One of the band 7’s, Natalie, recounted an experience she had as a student nurse whilst in a tweet chat. She said “I had a busy patient in a cubicle, and I went home, drugs and obs all on time, balance right, handover went well. It was like a big ‘exhale’ I did it, it’s fine, I can do this!” And I am starting to believe that maybe I too will get there.

Admittedly, I have had some wobbles and shakes. But then I feel like I am making progress and that’s what matters. Being an NQN isn’t straight forward. But I am now starting to understand the “whys?” & “hows”. Don’t get me wrong. I have an absolutely *huge* way to go, but the theory I learnt in university is starting to click. And I enjoy what I do, and I think that is so so important. Sure, some days I feel like I am drowning, but I have never been in a mindset of “I’ve had enough and don’t enjoy my job.”

Retention of the NHS workforce is a long overdue focus and there is much to do, however we are pleased we are starting to see some early improvements – Professor Mark Radford RN, Director of Nursing – Improvement, NHS Improvement


Mark Radford

Retention of the NHS workforce is a long overdue focus and there is much to do, however we are pleased we are starting to see some early improvements – Professor Mark Radford RN, Director of Nursing – Improvement, NHS Improvement

19 months ago NHS Improvement was commissioned by the Secretary of State for Health to launch a retention programme to support trusts in the retention of clinical staff and to share knowledge, tools and best practice across the sector.

Over the last 12 months period we have done exactly this.  In the first instance, in partnership with NHS Employers we have led and delivered six retention masterclasses for over 500 participants from NHS providers. Through these, 110 NHS trusts (nearly 50% of all trusts) that were experiencing higher staff turnover rates received direct tailored support from us over a 90 day period. And where our cohorts are engaging fully with the programme staff turnover rates are going down. 71% of our nursing and mental health cohort 1 trusts (25 out of 35 trusts) have noted improvement in their staff turnover rates since starting the programme.

Our work with the trusts to support improvements in staff turnover rates has been published on the NHS Improvement hub website – Staff retention support programme: one year on.  This shares our outcomes through the use of a direct support model and the provision of national learning resources available to support providers. We have since developed and secured funding for national roll out to all provider organisations.

In terms of early year career support and newly qualified nurses (NQNs), there is a high turnover (at a median of 24% in most places), and for some Trusts this is because staff are moving on for better opportunities. Sadly this is not always the case: the reality for some early years nurses is that they have a very poor experience. They are often not supported beyond the preceptorship period, which is of varying quality and then many NQNs are left to fend for themselves. NQNs are also looking for career support and mapping at 1, 2 and 5 year horizons and they want someone to help with this. We know that early years nurses will stay if they feel valued – we all need to work harder to do this,  through career support, pastoral care and educational offer such as CPD.


For more information about our programme please email NHSI.Workforce@nhs.net , follow us on twitter @NHSImprovement #NHSRetention you can also contact us to suggest a retention resource you use or have developed via this link https://improvement.nhs.uk/account/suggest-resource/

Student nurse to the real job as a real nurse is a whole different kettle of fish! Book review of “How to thrive as a newly qualified nurse”- (Carol Forde-Johnson) by Sharon Sanford (Newly Qualified Nurse)

how to thrive - book picAs a Newly Qualified Nurse (NQN) it’s both exciting and scary to transition into your first role. I know this because it’s how I feel, and my peers feel the same.  Student placements are fine and go some way to preparing you for life as a NQN and by the end of the third year I knew I could fit in with a new team, learn new skills and achieve my objectives but that confidence comes in part from knowing you are looked after by the University. Starting a real job as a real nurse is a whole different kettle of fish! A million questions run riot in my head, everything from what will the team expect of me? What tools will I use to keep my patients safe? How will I know if my documentation is good enough? What if something goes wrong…the list is endless. It would appear that the answers to these questions and many others can be found in this book.

Sharon Sandford
Sharon Sanford

A few weeks ago I stumbled across a competition to win a book ‘How to thrive as a newly qualified nurse by Carol Forde-Johnston’. http://www.lanternpublishing.com/titles/413-9781908625519-how-to-thrive-as-a-newly-qualified-nurse I was lucky enough and well chuffed to win a copy as I never win anything. Anyway this book reads like you’ve got the loveliest mentor you’ve ever had holding your hand through the transition from student nurse to qualified nurse. Just reading it made me feel calmer and better prepared about my imminent start.  In my opinion Carol Forde-Johnson’s book is the best transition book I’ve read. The book covers everything from interviewing for your new post to thinking about career progression. The interview section is really useful, it gives examples of interview questions you might be asked but also asks you to think through the answers you might give which, in my opinion helps you to decide if this really is the right role for you, useful for anyone unsure where they might like to work, after all there are thousands of Band 5 roles out there.  A bit of forethought and advance preparation might help you find the right role first time.

The chapters are all equally useful but the stand out chapter is structuring your learning in the first three months. There is no standardised preceptorship package and the onus on learning is down to me, as yours will be with you. I see taking ownership of my learning as removing some of the burden from my team.  Each chapter has a “what to do next” section, these are very useful and nursing gold akin to coming on shift to find that it is fully staffed! I’ll be able to apply these and make SMART goals towards my own personal development plan.

Carol Forde-Johnston does attempt to cover lots of issues about nursing in a variety of settings, but one teeny tiny flaw with the book is that it is written predominantly with a ward focus as is the case with the majority of books and articles. Maybe the lack of primary care resources stem from the days when a newly qualified had to go onto a ward as a first role, or maybe it’s just that primary care nurses haven’t gotten round to writing books on transition yet?  There is a gap, especially as there is a real drive to treat people away from the acute sector and keep people well at home for as long as possible. Added to which, a NQN can now go into a variety of roles in General Practice and Community Nursing, a book for us and the challenges specific to issues such as lone working would be a godsend.

Having said that, and despite the fact I am going off to be a community nurse I still found this book to be invaluable. So much so that I’m going to keep it (normally I pass books on to benefit others) but I know I will be referring back to this one. My advice to you is if you know a final year student nurse or a NQN tell them to have a look at this book.