The NHS is losing nurses faster than it can employ them, resulting in an ageing workforce. Drawing on interviews with policy-makers, employers, older nurses and other stakeholders, this report looks at what encourages nurses over 50 either to stay in the NHS or to leave. The report:
- Assesses the measures aimed at addressing the shortage of nurses and exposes the gap between policy and practice;
- Explores the options, decisions and outcomes for older nurses, drawing out the more general lessons for the employment of this age group;
- Argues that current measures fail to recognise the role that older nurses could play in the NHS and make recommendations for policy and practice to remedy this.
Working patterns and retirement decisions of people over 50 have important implications for labour supply in an ageing workforce, nowhere more so than in a sector such as the National Health Service threatened with severe staff shortage. In this context, a study by researchers at the University of Hull examined the options and decisions taken by nurses over 50, and the outcomes in terms of their movement in and out of the NHS. They found that:
- The NHS has an ageing nursing workforce with more than 75,000 nurses aged over 55 and a further 71,000 aged 50-54. Almost 10,000 nurses retire each year. Many nurses over 50 ('older nurses') remain in nursing in the National Health Service (NHS) but growing numbers take early retirement. A small number return to nursing in their 50s.
- Despite government efforts to stem the loss of nurses from the NHS and to promote return to practice, older nurses lack clear advice, guidance and encouragement about the options they may take, when considering whether to retire or remain in nursing, and when deciding whether to return to NHS nursing from the outside.
- Attitudes to older nurses are sometimes ambivalent, sometimes apathetic and sometimes welcoming. Some older nurses reported ageist attitudes towards them by employers and their personnel departments, although employers also valued particular qualities that they associated with older nurses.
- Older nurses reported particular needs, but not much effort by employers to meet these. In particular:
- They recognise their need for continuing professional development to help them keep up with a rapidly changing service, especially when returning after a career break. Yet opportunities are variable, and not geared towards the specific needs of older nurses.
- Physical limitations or family caring responsibilities mean that some nurses would like to have less heavy duties or to reduce hours of work, but they report limited flexibility by employers in this regard.
- Financial considerations may deter nurses from taking less demanding jobs, since this may compromise final pension entitlements.
- Return to practice initiatives are not tailored towards the needs of older nurses.
- Overall, stakeholders in the nursing workforce, including senior NHS and nursing managers, human resources personnel, retirement organisations and trade unions, admit to a poor translation of government policy into practice in relation to older nurses in the NHS.
The NHS has an ageing nursing workforce, with a growing proportion over 50, a declining proportion under 30 (see Figure 1) and 7 per cent leaving the nursing register annually. The age shift is compounded by a prevailing shortage of nurses. Many nurses are entering a phase of their working lives when existing pensions, employment and social conditions may make retirement an attractive option compared with remaining in nursing over the age of 50. In the light of current staff shortages, it is important to understand what older nurses perceive as being their employment options, what factors influence their employment-related decision-making and how they can be encouraged to remain active in the profession for as long as possible.
This study sought to investigate the employment of nurses over 50 in terms of options, decisions and outcomes. It found that policies relevant to nurses over 50 are not always evident in practice, and that a major requirement of nurses over 50 is personally relevant information about pensions and retirement and flexibility in their work.
Factors influencing older nurses' employment decisions
Employers, policy-makers and advisers all identified a range of influences on nurses' employment decisions, including negative aspects of work that led nurses to want to leave as well as positive reasons for staying in nursing or for being attracted to retirement.
Negative reasons included:
- The pace of technological change: views amongst employers that older nurses found it hard to cope with new demands of a modern NHS were often shared by older nurses themselves. This was particularly true of nurses returning after a career break.
"If you put me in the middle of an acute surgical ward with all of these pumps and machines going, I am not up to it." (Retired nurse)
- Stress: many older nurses admitted to feeling "worn out", and cited this as a significant influence on retirement decisions. This was particularly associated with clinical nursing; some older nurses felt that they could keep up work if they were transferred to administrative jobs. Stress was also associated with high staff turnover and related extra pressures, which can in turn be exacerbated where they result in more staff leaving the NHS.
Positive reasons included:
- Flexible hours, both employers and nurses identified this as a key influence on nurses' decisions to return to or remain in work. This was linked both to employment-related matters such as continuing professional development and to external factors such as caring for older relatives.
- Financial influences appear to be growing in importance as a factor, as an increasing proportion of older nurses rely on their own salary and pensions rather than those of a partner or spouse. Some nurses are inclined to stay longer to top up their pension. However, those who do not have a pension (for example, because they have worked part-time) have less incentive and some nurses feel there is no point working past 60 because they cannot accrue further pension rights.
- Availability of opportunities for continuing professional development, especially for nurses returning to work who are uncertain about whether they will be able to cope with the demands of a changing service.
Older nurses' needs and employer responses
The general picture uncovered by this research is that employers have been trying to address a wide range of nurses' needs to improve recruitment and retention, but they have not specifically focused on the needs of older nurses. For example, there is little evidence that hospital trusts have widely adopted measures to deal with older nurses' stress, although where trusts have taken such measures, for example trying to improve the skill mix of nurses and reduce usage of temporary staff, they can be effective.
General initiatives to improve work-life balance, such as the NHS's Improving Working Lives Campaign, have also not related specifically to older nurses. Nurses seeking options for more flexible hours as an alternative to early retirement had not tended to find such opportunities. Sometimes when there is a possibility of downshifting, financial factors act as a disincentive. The fact that the NHS superannuation scheme is based on final salary means that an end-of-career period in a lower grade can affect pension levels adversely. There is potential to introduce more flexibility into pension and work arrangements, though none of the cases covered by this research had so far addressed this.
If older nurses wish to remain in practice or to return to practice then they are entitled to continuing professional development and 'return to practice' training - the latter a mandatory requirement for nurses who have recorded a break in their practice. However, here again respondents reported that practice is not geared towards the needs of older nurses, and some felt that the focus was on younger recruits. Although it is difficult to design courses specifically on the basis of age, there is scope for more thought about designing and advertising courses around particular issues that older nurses face, including returning with out of date skills and developing new areas of expertise that enable them to move to less stressful or less physically demanding jobs.
"... coming back into practice and acting in a way where you shadow somebody for a while would help. That isn't what happened for me. You know, I came back as the new grade nurse ... and I remember going home thinking I don't know what ... I am doing." (Older nurse)
Advice and information about work options
Nurses reported getting little or no information or advice from their employers about their options with regard to remaining in the NHS, retiring or returning to work. However, it was quite common for nurses to make their own enquiries about employment and retirement options without the aid of their employer, using such resources as the internet. Much advice came by word of mouth from colleagues. A picture emerges of nurses at a particular stage in their life and career requiring sound advice prior to making any decisions but who, essentially, are left to their own devices.
Age and ageism
Some employers in the study admitted that they preferred to employ younger nurses and that policies, including return to practice initiatives, were not designed for older nurses. These views seemed to rest on perceived lack of potential among older nurses to grasp new technology along with apparent declining physical fitness and inability to cope with the stress of the job.
"It is the younger ones who are obviously important for the future, and that is therefore where our attentions are more focused." (Employer)
Some older nurses were, themselves, anxious about their ability to cope with some aspects of nursing:
"I think you slow up ... and I think the management needs to understand ... You shouldn't have to go cap in hand and say 'look I'm slowing up ...' [Management needs] to be more aware that people do have different needs when they get older."
However, in general, the older nurses did not feel that they experienced overt ageism from their employers. More often, they felt pressure from other colleagues, young and old, to retire soon and open up a job for a younger person. Many older nurses interviewed said they were coping well with the physical and mental demands of nursing over 50. Similarly, employers voiced many positive views about older nurses in the workforce; they emphasised that older nurses should be valued and not channelled into certain areas of nursing. In their experience, older nurses had qualities of courtesy and commitment, which were sometimes lacking in younger nurses, as well as a more deeply-rooted understanding of the needs of patients.
Conclusions and policy implications
These findings show clearly that the NHS has not been devoting specific attention to nurturing older nurses as a valuable resource. The result is that nurses feel that they are not being helped by their employers to address difficulties associated with growing older in a rapidly changing service. This undoubtedly contributes to earlier exit from nursing than might otherwise be the case. Yet there is much potential to reduce these difficulties and to make nursing more attractive, by focusing on the particular needs of older nurses, including those returning to the profession. The study highlights the need for:
- nurses over 50 to be informed about employment, retirement and return to work options;
- nurses over 50 to be offered flexible employment options;
- sources of information to be improved, and to become more 'personal', accessible and comprehensible;
- return to practice programmes to address the unique needs of older nurse;
- 'family-friendly' policies to become more evident to nurses, and not just to be limited to nurses with young children.
- personnel provisions that focus in particular on how older nurses' expertise may be best used to maintain high standards of professional care and as a possible source of labour to address current staff shortages.
About the project
The research was conducted over 12 months by a team based at the University of Hull. Using interviews and focus groups, the study was comprised of three stages:
- a review of the literature;
- interviews with key stakeholders in the UK, including employers, advisers and policy makers in the area of nurse employment;
- interviews with 84 nurses over 50 in the UK.