lnr. 1. .Surs. Stud.. Vol. 27. No. 3. pp Prinrcd m Great Bnram.
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M)?o-7489/90 $3.00 - 0.00 C I990 Pergamon Press pit
i990
Attitudes to a return to nursing: a survey in the Norwich Health District GRAHAM BENTHAM, M.A. and ROBIN HAYNES, B.A., Ph.D. School of Environmental Sciences, University of East Anglia, Norwich, U.K.
crisis in the recruitment of nurses is expected in the mid-1990s. One possible strategy is to attract trained nurses who have left active nursing back into the service. This study seeks to identify non-practising nurses in the Norwich Health District and find out what changes would be most likely to attract them back to nursing. .Most of the 642 non-practising nurses who responded to the survey had left the service relatively recently and the most common reason for leaving was pregnancy. Over half of the respondents said that it was likely that they would return to nursing at some time in the future. Younger females were the most likely to indicate an interest in returning. There was widespread agreement on the measures that would be most successful in attracting trained nurses back into the service. The suggestions that received most support were almost all concerned with providing opportunities for parttime nursing work with hours to suit women with children of school age. The register of non-practising nurses established by this survey will be maintained, updated and used as the basis for regular contact with a potential labour force. Abstract-A
Introduction
In the 1990s the nursing profession in the United Kingdom will face a daunting problem of attracting suitably qualified recruits. The advent of single level nurse training will coincide with a substantial reduction in the number of suitably qualified young entrants as a result of the falling birthrate in the 1970s. To illustrate the scale of the problem, Reid (1986) has calculated that to sustain a one per cent annual growth in nurse manpower the profession would need to recruit nearly half of the suitably qualified cohort in the early 1990s. Given that other employers will also be actively recruiting from this shrinking pool, the prospects 281
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for attaining such targets are not good. It is clear that the National Health Service (NHS) will have to look elsewhere if it is to meet its demand for nurses. One possible strategy is to attract back into the NHS a greater number of qualified nurses who have left the service. The Institute of Manpower Studies (IMS, 1985) has estimated that about 40 per cent of entrants to NHS nursing are qualified staff re-entering the profession. However, information on qualified but non-practising nurses is scarce (Reid, 1986). The most extensive source of data is a survey of non-practising nurses carried out by the Office of Population Censuses and Surveys in 1971 (Sadler and Whitworth, 1975). This estimated that in Britain there were 105,000 female qualified nurses who were not nursing. Amongst the sample interviewed the most common reason for leaving was pregnancy. Almost two-thirds of respondents expressed a wish to return to nursing at some time in the future. Since 1971 there have been important changes in both the profession itself and in the demographic and labour market environment in which it has to operate. More recently, the Institute of Manpower Studies has conducted a study of the attitudes, employment and mobility of a sample of Royal College of Nursing (RCN) members (Waite and Hutt, 1987; Waite et al., 1989). This detected different attitudes towards nursing amongst qualified nurses working in the NHS compared with those not working in the NHS. The sample included a small proportion (about 5 per cent) of nurses not working in a job related to nursing, and also a larger proportion (14 per cent) in nursing jobs outside the NHS. These groups were combined in the analysis. The authors were careful to point out that their sample (fully paid-up RCN members) was not a representative sample of the general pool of nurses outside the NHS. The main focus of the study was on nurses in employment, so no questions on the likelihood of returning to nursing in the future were included. Because of these differences the results of the IMS survey are not directly comparable with those from OPCS. There is therefore still a need for up-to-date information on which the NHS might base a strategy of encouraging qualified non-practising nurses to return to nursing work. The purpose of the study reported here is to repeat part of the OPCS investigation in one health district, to find out what changes in conditions of employment are required in the early 1990s to attract trained nurses back into the NHS. A second aim was to implement a recommendation of the Royal College of Nursing (Dean, 1987): to identify a local reserve of non-practising nurses in order to focus future recruitment efforts. Finding the non-practising nurses was a prerequisite of the questionnaire survey. Although all qualified nurses should, in theory, be registered with the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, a very high proportion of the addresses (and maiden names of women) of non-practising nurses on the national register are out of date. Recent attempts to bring the register up to date have been much more successful with active nurses employed in nursing jobs than with non-practising nurses (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, personal correspondence). Health authorities cannot therefore rely on this source to supply the required names and addresses, and neither do they have access to individual census returns, so they must seek the information locally. Method
The study sought trained nurses of both sexes who were not working in nursing. It was conducted in the Norwich Health District, one of the largest districts in the country, covering 1175 square miles and over 450,000 population. Almost half the population live in the city
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of Norwich or within commuting distance. The remainder of the district is rural, with a scatter of market towns and small villages. The first stage was to contact as many non-practising nurses as possible by means of a reply-paid postcard delivered to households in the Norwich Health District. Under the heading “Is there a nurse in your family ?” the card requested that all qualified nurses, midwives or health visitors not currently practising should fill in their name, address and qualifications and post it back to the Director of Nursing. A commercial company was contracted to deliver 185,000 cards. This number was sufficient to cover every household in the district, but informal checks revealed that many households did not receive a card. No formal verification was possible with the resources available, so the return rate could not be calculated. The outcome was that 775 postcards were returned. Cards were received from all parts of the district, but the proportion of returns from the more rural areas outside Norwich (45 per cent) was less than the proportion of population living in those areas (58 per cent), suggesting that relatively fewer deliveries had been made in rural areas than in urban areas. The second stage was to send a self-completion questionnaire to nurses of working age who had returned a postcard. The questionnaire sought the name, address, age, sex and nursing qualifications of the respondent, details of the respondent’s youngest child and other dependants, current employment status, car availability and the date and reason for leaving the last nursing job. Respondents’ opinions on the likelihood of their returning to nursing and the changes that would be most successful in attracting them back \vere also requested. Most of the questions were either taken directly or slightly adapted from the OPCS ‘Reserves of Nurses’ interview schedule (Sadler and Whitworth, 1975) so they had already been independently validated. In all, 642 completed questionnaire forms were received, a response rate of 82 per cent. Statistical tests were performed, where necessary, using the chi-square test at the 0.01 significance level. Results
Characteristics of respondents
Most respondents (95 per cent) were women. A broad spread of ages was represented with a preponderance in the age range 25 to 44 years. Most respondents had children, including more than a third whose youngest child was of pre-school age. A much smaller number (8 per cent) had someone else such as a disabled or elderly relative who they had to look after. Fewer than half of the respondents had a paid job at the time of the survey but 61 per cent had’s car available for use during the day at a time when they might ivish to work. The respondents held a diverse range of nursing qualifications, although registered general nurses (386 in the sample) and enrolled general nurses (179 respondents) were numerically dominant. Large numbers of midwives (104 respondents) and psychiatric nurses (70) were also represented. Almost all of these groups contained only small proportions of men, with the exception of psychiatric nurses, of whom 29 per cent were men. The age distribution between the above-mentioned groups was similar, except that the enrolled nurses contained proportionally more people under the age of 35 and less older respondents than the other groups. Reasons for leaving nursing
Whilst some respondents had been away from nursing for many years, more than half had worked in nursing within the previous seven years and one-fifth had left their last nursing
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Table I. Likelihood of return to nursing, by age
Age Under 2S (N=22) 25-34 (N= 227) 35-44 (N= 179) 45-54 (N= 105) 55 or over (N= 102) All respondents (N= 635)
Very likely
Fairly likely
59 46 37 12 8 32
27 32 24 15 5 22
Likelihood of return (q/o) Fairly Very unlikely unlikely 9 6 II 20 26 13
0 4 7 24 44 14
Can’t say
No reply
4 12 20 27 8 15
0 2 2 2 10 4
job within two years. This preponderance of relatively recent leavers was an anticipated feature of the survey. Many trained nurses who left nursing some time ago might have already returned to nursing, become established in another job or decided against taking up paid employment. Any of these situations.would make it less likely that they would be included in the survey. The most common reason given for leaving the last nursing job was pregnancy or the birth of a child (44 per cent of replies). Moving away from the area in which they had been working was the next most common reason (18 per cent). Smaller numbers mentioned dissatisfaction with nursing (12 per cent) and dissatisfaction with pay (8 per cent), but these factors were considerably more important for some types of respondents. For example, 36 per cent of males in the sample said dissatisfaction with pay was important in their decision to leave nursing. Amongst respondents without children, pay was a factor for 18 per cent and 29 per cent mentioned dissatisfaction with nursing.
Returning to nursing One objective of the survey was to gauge the extent to which nurses not currently working in the profession were likely to return. The question asked was “Taking everything into account, as far as you can tell at present, how likely is it at some time in the future you will try to get a nursing job of any kind ?” The responses to this question are summarised in Table 1. Altogether 15 per cent of respondents who answered the question were unable to say how likely their return to nursing would be. Those who were undecided about the future tended to be aged 35-55, with older children or other dependants, and those who were qualified as enrolled general nurses or psychiatric nurses. For the sample as a whole, there was evidence of considerable interest in returning to nursing. Altogether, 32 per cent of respondents said that it was “very likely” that they would return and 22 per cent said that their return was “likely”. These respondents outnumbered those saying their return was unlikely by about two to one. More detailed analysis revealed differences within the sample. In particular, the likelihood of return diminished markedly with age. This relationship was statistically significant. While the great majority of respondents up to the age of 35 expressed a wish to return to nursing, the proportion was highest in the under 25 age group and declined steadily from then on. Because it is younger women who tend to have small children to look after there was also the same trend with age of youngest child. Likelihood of return was considerably less for those with dependants such as elderly or disabled relatives. It was also less in the city and suburbs than in other parts of the district. Those with an enrolled nursing qualification were more likely to plan to return than others. All these differences were statistically significant. Health visitors were significantly less likely than others to plan to return, as were midwives although at a reduced
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Table 2. Years until return to nursing Years All respondents (N= 642) By age of youngest child: O-4 years (N=217) 5-11 years (N= 127) 12-16 years (N=53) Over 16 years (N=99)
Now
1
2
I1
13
12
10 14 13 12
16 13 17 11
19 13 11 5
Woo)
No answer
3-5
6+
18
4
42
32 24 11 4
6 9 0 0
17 28 47 68
level of statistical significance (0.05). The men in the sample appeared less likely than the women to return, but the difference was not significant. No marked differences were apparent between those who had a paid job and those without (57 per cent of respondents who did not have a paid job said they were likely to return and the equivalent figure was 54 per cent of those who had a paid job). Nor did car ownership seem to have any effect. As well as gauging whether respondents expected to return to nursing the questionnaire also asked when this was likely to be. A high proportion of respondents (42 per cent) declined to make an estimate of the time period before they would be likely to return, but more than half did give an indication (see Table 2). For the sample as a whole approximately one-tenth (69 nurses) said they were ready to return immediately. Most respondents placed their likely return some time into the future, with the most common reply being three to five years hence. Altogether 345 trained nurses (54 per cent of the sample) said that if they were to return to nursing the most likely time would be within the next five years. Timing of return will clearly be dependent on factors such as changing family commitments as can be seen from the relationship between expected date of return and age of youngest child shown in Table 2. In particular.those with young children were more likely to choose a return to nursing three to five years from now than other respondents. Former nurses with older children were less sure about returning to nursing. Those who did give a possible date tended to opt for an early return. These differences were statistically significant. Preferred types of nursing The most preferred type of nursing was work in a large acute hospital (chosen by 39 per cent). Nursing in a small community hospital was only slightly less popular (35 per cent). In general, older respondents were more likely to prefer work in community hospitals, while more of the younger respondents opted for large acute hospitals. District nursing was the first choice of 13 per cent of respondents. Other types of nursing were attractive to smaller numbers of respondents, generally reflecting the numbers with specific relevant qualifications. Psychiatric nursing attracted 11 per cent of the sample, while 7 per cent and 5 per cent respectively of respondents said they preferred to work as a midwife or health visitor. It is worth noting that whereas over three-quarters of qualified psychiatric nurses said they would wish to return to psychiatric nursing, only 36 per cent of qualified midwives expressed an interest in midwifery and the corresponding figure for health visitors was 41 per cent. Attitudes to possible changes Fourteen suggestions that have been put forward for attracting trained nurses back into the NHS were outlined and respondents were asked to consider how successful each would be in attracting them back to nursing. It is clear that the suggestions were judged to have
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Table 3. Attitudes to possible changes which would attract respondents back to nursing
Possible changes Better basic pay Pay for unsocial hours Improved nurse/patient ratios Part-time work opportunities Working time to suit the nurse Hours to fit schooling Time off when children ill Creche/nursery school Facilities for school children Transport Share job More senior posts Refresher course Trial period
Very successful 46 44 48 73 67 58 54 37 38 22 I5 39 71 48
Whole sample (@IO) Not Successful successful 37 36 34 14 17 12 16 16 21 27 23 27 15 26
a 9 7 6 5 13 12 25 22 35 44 20 4 18
No answer 10 II
12 8 10 17 17 22 18 16 18 14 10 8
very different prospects of success (Table 3). Five of the suggestions were considered to be likely to be very successful by at least half of the respondents. Most of these were concerned with ways in which nursing could be made to fit in better with family responsibilities. The suggestion rated as likely to be very successful by the largest number of respondents (73 per cent) was opportunities for part-time work. Nearly as many emphasized the importance of working times which suited the individuals concerned. Hours to fit in with children’s schooling and time off when children are ill were also deemed to be likely to be very successful by a majority of respondents. In the words of one nurse, “I feel very strongly that if conditions were greatly improved to consider children’s schooling and illness, also husbands’ working hours, many nurses would be willing to return to work”. The other striking feature of the results is the importance attached to the suggestion of a refresher course for those who return to nursing. Many expressed views in sympathy with the comment that “a refresher course is an excellent idea as many women lose confidence in their ability to go back to nursing after an absence”. While improvements in the flexibility of working hours and the provision of a refresher course attracted the largest proportion of “very successful” responses, suggestions concerning improvements in pay and conditions of work were also widely regarded as likely to be successful. Between 40 and 50 per cent of respondents said they thought that better basic pay, higher pay for unsocial hours, improved nurse/patient ratios and letting those thinking of returning to nursing go back for a few days to see how they like it would be “very successful”. It is worth noting that pay and conditions of work appear to be critical issues for less respondents than the need for improvement in the flexibility of working hours. As one respondent said: “All the money in the world would not help if my family weren’t considered, that is why I feel more flexible working hours are important”. The other suggestions all achieved fewer than 40 per cent of respondents judging them likely to be very successful. Creches or nursery schools, facilities for school children in holidays and more senior posts for part-time nurses all attracted minority support. Relatively few respondents thought that the health service providing transport from home to work or the prospect of sharing a job with a spouse or friend would be very successful in attracting them back.
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Table 4. Attitudes to possible changes by age of respondent (S) Responding “very successful” Age of respondent Possible changes
Under 25
25-34
35-44
45-54
55+ 36 35 49 51 49 34 31 32 22 33 20 ti 69 66 102
Better basic pay Pay for unsocial hours Improved nurse/patient ratios Part-time work opportunities Working time to suit the nurse Hours to fit schooling Time off when children ill Creche/nursery school Facilities for school children Transport Share job More senior posts Refresher course Trial period
59 59 54 7-l 73 68 68 73 59 I4 4 27 73 I8
53 52 52 76 18 71 68 58 49 19 15 33 66 32
43 41 42 71 70 6-t 24 41 20 17 42 78 5-I
41 38 45 73 56 29 28 I4 21 23 12 48 73 63
Total N
22
227
179
105
71
Attitudes and characteristics of the nurses Views on the likely success of different suggestions appeared to be influenced by the differing circumstances of respondents; how the attitudes to different suggestions differed depending on the age of the respondent is shown in Table 4. Few differences were apparent in terms of opportunities for part-time work or for refresher courses, which were supported by substantial numbers in all age groups. Refresher courses were supported by a substantial majority even of nurses who had left only in the last few years. One nurse expressed the view that “a refresher course is imperative for nurses returning to work even after a break of only two years”. Elsewhere there were some marked differences. The younger age groups gave significantly greater support than the older groups to the suggestions which aimed to increase the compatibility between working in nursing and responsibilities for child care. Better basic pay and pay for unsocial hours also received more support from younger respondents than they did from those who were older, but only at the 0.5 significance level. The opposite trend was apparent for the suggestions of health service transport to work, more posts for part-time sisters and senior enrolled nurses and a trial period for nurses thinking of returning, which all received significantly greater support from older respondents. The idea of returning for a trial period was particularly popular among the respondents who had been out of nursing for the longest time. The pattern of responses revealed in Table 4 confirms that policies to attract trained nurses back into the service can be aimed at particular age groups. Providing the opportunity for a trial period or making more senior posts available will be more attractive to older nurses. If health authorities wish to concentrate their efforts on attracting younger nurses, then providing opportunities for more flexible part-time work with some arrangements for children offers the greatest potential. Many would echo one respondent’s comment that “I do not feel recognised as a mother in the health service and that’s why my career came to a standstill”. The suggestions relating to school children not surprisingly found most support amongst respondents who had children aged 5-l 1, but that group was less concerned about creches
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Table 5. Attitudes to possible arrangements
R0BI.V
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for children, by age of youngest child (oio) Responding “very successful” Age of youngest child
Possible changes Part-time work opportunities Working time to suit the nurse Hours to fit schooling Time off when children ill C&he/nursery school Facilities for school children Total N
12-16
16+
No child
89 83 87 80 23 55
70 57 45 49 19 I5
67 59 26 26 18 22
50 46 26 23 30 21
127
53
99
146
o-4
5-11
a2 80 79 76 64 52 217
or nursery schools than the respondents with younger children (Table 5). Respondents with no children were, predictably, less enthusiastic about the suggestions concerning children and relatively more enthusiastic about the suggestions to do with general conditions of work and pay. Large differences in attitudes were apparent when the sample of respondents was divided into males and females. With the exception of better basic pay, all the suggestions received a more enthusiastic response from females than from males. In particular, the suggestions concerning flexible part-time work and those concerned with arrangements for children were strongly supported by a high proportion of women but a low proportion of men. The differences were significant, in spite of the small number of men in the sample. These results offer very little encouragement for measures to bring back male trained nurses into the service. One man pointed out that “I would need the basic pay to be greatly increased to support a family and mortgage for me to return to nursing”. A breakdown of respondents by qualification, on the other hand, revealed only small differences in attitudes. Whether or not the respondent was currently working in another job seemed to have a slight effect. Predictably, those with paid jobs were more likely to judge improvements in pay and promotion prospects as likely to be very successful in attracting them back to nursing than those without jobs (at the 0.05 level). Conversely, they were significantly less enthusiastic about suggestions of working hours to fit in with children’s schooling and time off when children are ill, compared with the group without paid jobs. But apart from these differences the responses from those working and those not working in paid jobs were remarkably similar. For both groups, flexible part-time work and a refresher course were the most attractive suggestions. The changes promising to be most successful in attracting trained nurses back into the service are thrown into sharper relief by focusing on those who consider themselves likely to return to nursing. Enthusiasm for most of the suggestions was significantly lower amongst those who thought their return was unlikely and higher amongst those who expected to return (Table 6). It is clear that recruitment efforts have the greatest chance of success if they concentrate on the latter group. Amongst the nurses who said they were likely to return, the two issues of primary importance were more opportunities for part-time work and working times to suit the individual. Third in importance was a refresher course. Next were hours to fit in with children’s schooling and time off when children are ill. Other factors, such as facilities for babies or children, better pay and better nurse/patient ratios were stongly supported, but their appeal was less than that of the major factors identified above.
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Table 6. Attitudes to possible changes by likelihood of return to nursing (olo) Responding “very successful” Likelihood of return Very Very Fairly Fairly unlikely likely unlikely likely 50
48 49 80 7-l 68 65 47 48 23 18 42 68 37
47 45 49 82 80 73 68 44 42 20 13 38 78 49
42 44 53 65 57 42 42 26 25 22 12 44 73 59
35 29 41 45 40 34 29 30 22 I9 16 35 60 5:
205
142
81
91
Better basic pay Pay for unsocial hours Improved nurse/patient ratios Part-time work opportunities Working time to suit the nurse Hours to fit schooling Time off when children ill Creche/nursery school Facilities for school children Transport Share job More senior posts Refresher course Trial period Total N
Discussion
The results reported here did not come from a random sample. It is not likely that the 642 former nurses who completed the questionnaire were representative of non-practising nurses generally. Those included in the survey had taken the trouble to complete and post two items, so the sample is expected to contain more people who are interested in maintaining contact with nursing and perhaps returning to the profession than the population of non-practising nurses as a whole. For an investigation of the factors most likely to be successful in bringing former nurses back to work, a bias towards the most highly motivated is a strength rather than a weakness. This investigation has confirmed that the findings of the national study conducted by OPCS in 1971 still hold. The most common reason for leaving nursing is still pregnancy. The majority of trained nurses not employed in nursing still express a wish to return to nursing at some time in the future, although the proportion appears to have fallen (from 64 per cent in the 1971 study to 54 per cent in the present enquiry). Given the probable bias towards enthusiastic respondents in our sample (which was not present in the OPCS survey), this 10 per cent reduction in the popularity of returning to nursing may well signal a real trend. The main barrier to recruitment remains the same. In 1971, as in this study, arrangements to enable mothers to look after their children while working part time were identified as the changes offering most potential for attracting former nurses back. While the overall situation may not have changed greatly since the OPCS survey 19 years ago, the present study has supplied details of the current scene in one part of the country. In the Norwich Health District, commitment to nursing and an interest in returning is highest shortly after leaving. Large numbers of nurses who wish to return to the profession have young children or other dependants to look after. Men, who tend to leave the service for other reasons, are less likely to plan to return. The higher proportion of nurses wishing to return who live outside the city is perhaps an indication of small untapped pools of labour away from the main centre of employment. The most surprising finding is that getting
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another job does not appear to diminish the intention of returning to nursing at some time in the future. It is the age of the youngest child which largely determines women’s availability for employment. Most former nurses with pre-school children indicated that a return in 2-5 years’ time was possible. Former nurses with older children were less inclined to wait, but fewer of them were interested in returning. There is little doubt that the key group with the highest probability of return is of young women who have recently left nursing in order to have children, According to their own assessments, the best time for them to resume nursing is shortly after the youngest child enters school. At present there are barriers that discourage this potentially large labour force from reentering the nursing profession. Pay and conditions of work must be taken into account, but these are less significant than the practical problems of doing a job and looking after children at the same time. The results of this survey indicate that the most promising course of action is to provide the opportunity for part-time work with hours to suit the individual concerned. In particular, the hours of work must make allowance for the demands made on mothers with children of school age. Such arrangements combined with a refresher course offer the best prospect of attracting large numbers of trained nurses back into the NHS. In the absence of an accurate national register, health authorities have a substantial problem in identifying the large numbers of non-practising nurses who live in their districts. A useful by-product of this research has been the establishment of a local register of nonpractising nurses. All nurses who leave NHS employment but who remain in the Norwich district from now on will be added to the register. It is planned to maintain contact with the nurses on the register by mailing a newsletter at regular intervals. The local register will be used to keep in contact with a potential workforce. At one level, a source of names and addresses will be valuable for circulating general information about vacancies and special arrangements as they become available. At a more detailed scale, the register could be used to focus on particular individuals: to contact, for instance, trained nurses with children who have reached a certain age or trained midwives living in a defined area. This will facilitate the more active recruitment strategy required for the 1990s. Acknowledgement-This study was funded by the Norwich Health Authority and was carried out in collaboration with the then Director of Nursing, Mr. R. Purcell. We are very grateful for his help.
References Dean, D. _I. (1987) hkrnpower Solurions. Royal College of Nursing, London. Institute of Manpower Studies (1985) TheManpower Implications ofPossible Changes in Basic Nurse Training. In Annexe of Research Studies for Commission on Nursing Education. Royal College of Nursing of the United Kingdom. Reid, N. G. (1986) Nurse manpower: the problems ahead. Int. J. Nurs. Stud. 23, 187-197. Sadler, J. and Whitworth, T. (1975) Reserves of Nurses, HMSO, London. Waite, R. and Hutt, R. (1987) Arfitudes, Jobs andMobility of Qualified Nurses. Institute of Manpower Studies Report No. 130, University of Sussex, Brighton. Waite, R., Buchan, J. and Thomas, J. (1989) NursesIn and Out of Work. Institute of Manpower Studies Report No. 170, University of Sussex, Brighton. (Received 13 September 1989; accepted for publication 23 February 1990)
287-2%.
M)?o-7489/90 $3.00 - 0.00 C I990 Pergamon Press pit
i990
Attitudes to a return to nursing: a survey in the Norwich Health District GRAHAM BENTHAM, M.A. and ROBIN HAYNES, B.A., Ph.D. School of Environmental Sciences, University of East Anglia, Norwich, U.K.
crisis in the recruitment of nurses is expected in the mid-1990s. One possible strategy is to attract trained nurses who have left active nursing back into the service. This study seeks to identify non-practising nurses in the Norwich Health District and find out what changes would be most likely to attract them back to nursing. .Most of the 642 non-practising nurses who responded to the survey had left the service relatively recently and the most common reason for leaving was pregnancy. Over half of the respondents said that it was likely that they would return to nursing at some time in the future. Younger females were the most likely to indicate an interest in returning. There was widespread agreement on the measures that would be most successful in attracting trained nurses back into the service. The suggestions that received most support were almost all concerned with providing opportunities for parttime nursing work with hours to suit women with children of school age. The register of non-practising nurses established by this survey will be maintained, updated and used as the basis for regular contact with a potential labour force. Abstract-A
Introduction
In the 1990s the nursing profession in the United Kingdom will face a daunting problem of attracting suitably qualified recruits. The advent of single level nurse training will coincide with a substantial reduction in the number of suitably qualified young entrants as a result of the falling birthrate in the 1970s. To illustrate the scale of the problem, Reid (1986) has calculated that to sustain a one per cent annual growth in nurse manpower the profession would need to recruit nearly half of the suitably qualified cohort in the early 1990s. Given that other employers will also be actively recruiting from this shrinking pool, the prospects 281
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for attaining such targets are not good. It is clear that the National Health Service (NHS) will have to look elsewhere if it is to meet its demand for nurses. One possible strategy is to attract back into the NHS a greater number of qualified nurses who have left the service. The Institute of Manpower Studies (IMS, 1985) has estimated that about 40 per cent of entrants to NHS nursing are qualified staff re-entering the profession. However, information on qualified but non-practising nurses is scarce (Reid, 1986). The most extensive source of data is a survey of non-practising nurses carried out by the Office of Population Censuses and Surveys in 1971 (Sadler and Whitworth, 1975). This estimated that in Britain there were 105,000 female qualified nurses who were not nursing. Amongst the sample interviewed the most common reason for leaving was pregnancy. Almost two-thirds of respondents expressed a wish to return to nursing at some time in the future. Since 1971 there have been important changes in both the profession itself and in the demographic and labour market environment in which it has to operate. More recently, the Institute of Manpower Studies has conducted a study of the attitudes, employment and mobility of a sample of Royal College of Nursing (RCN) members (Waite and Hutt, 1987; Waite et al., 1989). This detected different attitudes towards nursing amongst qualified nurses working in the NHS compared with those not working in the NHS. The sample included a small proportion (about 5 per cent) of nurses not working in a job related to nursing, and also a larger proportion (14 per cent) in nursing jobs outside the NHS. These groups were combined in the analysis. The authors were careful to point out that their sample (fully paid-up RCN members) was not a representative sample of the general pool of nurses outside the NHS. The main focus of the study was on nurses in employment, so no questions on the likelihood of returning to nursing in the future were included. Because of these differences the results of the IMS survey are not directly comparable with those from OPCS. There is therefore still a need for up-to-date information on which the NHS might base a strategy of encouraging qualified non-practising nurses to return to nursing work. The purpose of the study reported here is to repeat part of the OPCS investigation in one health district, to find out what changes in conditions of employment are required in the early 1990s to attract trained nurses back into the NHS. A second aim was to implement a recommendation of the Royal College of Nursing (Dean, 1987): to identify a local reserve of non-practising nurses in order to focus future recruitment efforts. Finding the non-practising nurses was a prerequisite of the questionnaire survey. Although all qualified nurses should, in theory, be registered with the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, a very high proportion of the addresses (and maiden names of women) of non-practising nurses on the national register are out of date. Recent attempts to bring the register up to date have been much more successful with active nurses employed in nursing jobs than with non-practising nurses (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, personal correspondence). Health authorities cannot therefore rely on this source to supply the required names and addresses, and neither do they have access to individual census returns, so they must seek the information locally. Method
The study sought trained nurses of both sexes who were not working in nursing. It was conducted in the Norwich Health District, one of the largest districts in the country, covering 1175 square miles and over 450,000 population. Almost half the population live in the city
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of Norwich or within commuting distance. The remainder of the district is rural, with a scatter of market towns and small villages. The first stage was to contact as many non-practising nurses as possible by means of a reply-paid postcard delivered to households in the Norwich Health District. Under the heading “Is there a nurse in your family ?” the card requested that all qualified nurses, midwives or health visitors not currently practising should fill in their name, address and qualifications and post it back to the Director of Nursing. A commercial company was contracted to deliver 185,000 cards. This number was sufficient to cover every household in the district, but informal checks revealed that many households did not receive a card. No formal verification was possible with the resources available, so the return rate could not be calculated. The outcome was that 775 postcards were returned. Cards were received from all parts of the district, but the proportion of returns from the more rural areas outside Norwich (45 per cent) was less than the proportion of population living in those areas (58 per cent), suggesting that relatively fewer deliveries had been made in rural areas than in urban areas. The second stage was to send a self-completion questionnaire to nurses of working age who had returned a postcard. The questionnaire sought the name, address, age, sex and nursing qualifications of the respondent, details of the respondent’s youngest child and other dependants, current employment status, car availability and the date and reason for leaving the last nursing job. Respondents’ opinions on the likelihood of their returning to nursing and the changes that would be most successful in attracting them back \vere also requested. Most of the questions were either taken directly or slightly adapted from the OPCS ‘Reserves of Nurses’ interview schedule (Sadler and Whitworth, 1975) so they had already been independently validated. In all, 642 completed questionnaire forms were received, a response rate of 82 per cent. Statistical tests were performed, where necessary, using the chi-square test at the 0.01 significance level. Results
Characteristics of respondents
Most respondents (95 per cent) were women. A broad spread of ages was represented with a preponderance in the age range 25 to 44 years. Most respondents had children, including more than a third whose youngest child was of pre-school age. A much smaller number (8 per cent) had someone else such as a disabled or elderly relative who they had to look after. Fewer than half of the respondents had a paid job at the time of the survey but 61 per cent had’s car available for use during the day at a time when they might ivish to work. The respondents held a diverse range of nursing qualifications, although registered general nurses (386 in the sample) and enrolled general nurses (179 respondents) were numerically dominant. Large numbers of midwives (104 respondents) and psychiatric nurses (70) were also represented. Almost all of these groups contained only small proportions of men, with the exception of psychiatric nurses, of whom 29 per cent were men. The age distribution between the above-mentioned groups was similar, except that the enrolled nurses contained proportionally more people under the age of 35 and less older respondents than the other groups. Reasons for leaving nursing
Whilst some respondents had been away from nursing for many years, more than half had worked in nursing within the previous seven years and one-fifth had left their last nursing
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Table I. Likelihood of return to nursing, by age
Age Under 2S (N=22) 25-34 (N= 227) 35-44 (N= 179) 45-54 (N= 105) 55 or over (N= 102) All respondents (N= 635)
Very likely
Fairly likely
59 46 37 12 8 32
27 32 24 15 5 22
Likelihood of return (q/o) Fairly Very unlikely unlikely 9 6 II 20 26 13
0 4 7 24 44 14
Can’t say
No reply
4 12 20 27 8 15
0 2 2 2 10 4
job within two years. This preponderance of relatively recent leavers was an anticipated feature of the survey. Many trained nurses who left nursing some time ago might have already returned to nursing, become established in another job or decided against taking up paid employment. Any of these situations.would make it less likely that they would be included in the survey. The most common reason given for leaving the last nursing job was pregnancy or the birth of a child (44 per cent of replies). Moving away from the area in which they had been working was the next most common reason (18 per cent). Smaller numbers mentioned dissatisfaction with nursing (12 per cent) and dissatisfaction with pay (8 per cent), but these factors were considerably more important for some types of respondents. For example, 36 per cent of males in the sample said dissatisfaction with pay was important in their decision to leave nursing. Amongst respondents without children, pay was a factor for 18 per cent and 29 per cent mentioned dissatisfaction with nursing.
Returning to nursing One objective of the survey was to gauge the extent to which nurses not currently working in the profession were likely to return. The question asked was “Taking everything into account, as far as you can tell at present, how likely is it at some time in the future you will try to get a nursing job of any kind ?” The responses to this question are summarised in Table 1. Altogether 15 per cent of respondents who answered the question were unable to say how likely their return to nursing would be. Those who were undecided about the future tended to be aged 35-55, with older children or other dependants, and those who were qualified as enrolled general nurses or psychiatric nurses. For the sample as a whole, there was evidence of considerable interest in returning to nursing. Altogether, 32 per cent of respondents said that it was “very likely” that they would return and 22 per cent said that their return was “likely”. These respondents outnumbered those saying their return was unlikely by about two to one. More detailed analysis revealed differences within the sample. In particular, the likelihood of return diminished markedly with age. This relationship was statistically significant. While the great majority of respondents up to the age of 35 expressed a wish to return to nursing, the proportion was highest in the under 25 age group and declined steadily from then on. Because it is younger women who tend to have small children to look after there was also the same trend with age of youngest child. Likelihood of return was considerably less for those with dependants such as elderly or disabled relatives. It was also less in the city and suburbs than in other parts of the district. Those with an enrolled nursing qualification were more likely to plan to return than others. All these differences were statistically significant. Health visitors were significantly less likely than others to plan to return, as were midwives although at a reduced
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Table 2. Years until return to nursing Years All respondents (N= 642) By age of youngest child: O-4 years (N=217) 5-11 years (N= 127) 12-16 years (N=53) Over 16 years (N=99)
Now
1
2
I1
13
12
10 14 13 12
16 13 17 11
19 13 11 5
Woo)
No answer
3-5
6+
18
4
42
32 24 11 4
6 9 0 0
17 28 47 68
level of statistical significance (0.05). The men in the sample appeared less likely than the women to return, but the difference was not significant. No marked differences were apparent between those who had a paid job and those without (57 per cent of respondents who did not have a paid job said they were likely to return and the equivalent figure was 54 per cent of those who had a paid job). Nor did car ownership seem to have any effect. As well as gauging whether respondents expected to return to nursing the questionnaire also asked when this was likely to be. A high proportion of respondents (42 per cent) declined to make an estimate of the time period before they would be likely to return, but more than half did give an indication (see Table 2). For the sample as a whole approximately one-tenth (69 nurses) said they were ready to return immediately. Most respondents placed their likely return some time into the future, with the most common reply being three to five years hence. Altogether 345 trained nurses (54 per cent of the sample) said that if they were to return to nursing the most likely time would be within the next five years. Timing of return will clearly be dependent on factors such as changing family commitments as can be seen from the relationship between expected date of return and age of youngest child shown in Table 2. In particular.those with young children were more likely to choose a return to nursing three to five years from now than other respondents. Former nurses with older children were less sure about returning to nursing. Those who did give a possible date tended to opt for an early return. These differences were statistically significant. Preferred types of nursing The most preferred type of nursing was work in a large acute hospital (chosen by 39 per cent). Nursing in a small community hospital was only slightly less popular (35 per cent). In general, older respondents were more likely to prefer work in community hospitals, while more of the younger respondents opted for large acute hospitals. District nursing was the first choice of 13 per cent of respondents. Other types of nursing were attractive to smaller numbers of respondents, generally reflecting the numbers with specific relevant qualifications. Psychiatric nursing attracted 11 per cent of the sample, while 7 per cent and 5 per cent respectively of respondents said they preferred to work as a midwife or health visitor. It is worth noting that whereas over three-quarters of qualified psychiatric nurses said they would wish to return to psychiatric nursing, only 36 per cent of qualified midwives expressed an interest in midwifery and the corresponding figure for health visitors was 41 per cent. Attitudes to possible changes Fourteen suggestions that have been put forward for attracting trained nurses back into the NHS were outlined and respondents were asked to consider how successful each would be in attracting them back to nursing. It is clear that the suggestions were judged to have
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Table 3. Attitudes to possible changes which would attract respondents back to nursing
Possible changes Better basic pay Pay for unsocial hours Improved nurse/patient ratios Part-time work opportunities Working time to suit the nurse Hours to fit schooling Time off when children ill Creche/nursery school Facilities for school children Transport Share job More senior posts Refresher course Trial period
Very successful 46 44 48 73 67 58 54 37 38 22 I5 39 71 48
Whole sample (@IO) Not Successful successful 37 36 34 14 17 12 16 16 21 27 23 27 15 26
a 9 7 6 5 13 12 25 22 35 44 20 4 18
No answer 10 II
12 8 10 17 17 22 18 16 18 14 10 8
very different prospects of success (Table 3). Five of the suggestions were considered to be likely to be very successful by at least half of the respondents. Most of these were concerned with ways in which nursing could be made to fit in better with family responsibilities. The suggestion rated as likely to be very successful by the largest number of respondents (73 per cent) was opportunities for part-time work. Nearly as many emphasized the importance of working times which suited the individuals concerned. Hours to fit in with children’s schooling and time off when children are ill were also deemed to be likely to be very successful by a majority of respondents. In the words of one nurse, “I feel very strongly that if conditions were greatly improved to consider children’s schooling and illness, also husbands’ working hours, many nurses would be willing to return to work”. The other striking feature of the results is the importance attached to the suggestion of a refresher course for those who return to nursing. Many expressed views in sympathy with the comment that “a refresher course is an excellent idea as many women lose confidence in their ability to go back to nursing after an absence”. While improvements in the flexibility of working hours and the provision of a refresher course attracted the largest proportion of “very successful” responses, suggestions concerning improvements in pay and conditions of work were also widely regarded as likely to be successful. Between 40 and 50 per cent of respondents said they thought that better basic pay, higher pay for unsocial hours, improved nurse/patient ratios and letting those thinking of returning to nursing go back for a few days to see how they like it would be “very successful”. It is worth noting that pay and conditions of work appear to be critical issues for less respondents than the need for improvement in the flexibility of working hours. As one respondent said: “All the money in the world would not help if my family weren’t considered, that is why I feel more flexible working hours are important”. The other suggestions all achieved fewer than 40 per cent of respondents judging them likely to be very successful. Creches or nursery schools, facilities for school children in holidays and more senior posts for part-time nurses all attracted minority support. Relatively few respondents thought that the health service providing transport from home to work or the prospect of sharing a job with a spouse or friend would be very successful in attracting them back.
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Table 4. Attitudes to possible changes by age of respondent (S) Responding “very successful” Age of respondent Possible changes
Under 25
25-34
35-44
45-54
55+ 36 35 49 51 49 34 31 32 22 33 20 ti 69 66 102
Better basic pay Pay for unsocial hours Improved nurse/patient ratios Part-time work opportunities Working time to suit the nurse Hours to fit schooling Time off when children ill Creche/nursery school Facilities for school children Transport Share job More senior posts Refresher course Trial period
59 59 54 7-l 73 68 68 73 59 I4 4 27 73 I8
53 52 52 76 18 71 68 58 49 19 15 33 66 32
43 41 42 71 70 6-t 24 41 20 17 42 78 5-I
41 38 45 73 56 29 28 I4 21 23 12 48 73 63
Total N
22
227
179
105
71
Attitudes and characteristics of the nurses Views on the likely success of different suggestions appeared to be influenced by the differing circumstances of respondents; how the attitudes to different suggestions differed depending on the age of the respondent is shown in Table 4. Few differences were apparent in terms of opportunities for part-time work or for refresher courses, which were supported by substantial numbers in all age groups. Refresher courses were supported by a substantial majority even of nurses who had left only in the last few years. One nurse expressed the view that “a refresher course is imperative for nurses returning to work even after a break of only two years”. Elsewhere there were some marked differences. The younger age groups gave significantly greater support than the older groups to the suggestions which aimed to increase the compatibility between working in nursing and responsibilities for child care. Better basic pay and pay for unsocial hours also received more support from younger respondents than they did from those who were older, but only at the 0.5 significance level. The opposite trend was apparent for the suggestions of health service transport to work, more posts for part-time sisters and senior enrolled nurses and a trial period for nurses thinking of returning, which all received significantly greater support from older respondents. The idea of returning for a trial period was particularly popular among the respondents who had been out of nursing for the longest time. The pattern of responses revealed in Table 4 confirms that policies to attract trained nurses back into the service can be aimed at particular age groups. Providing the opportunity for a trial period or making more senior posts available will be more attractive to older nurses. If health authorities wish to concentrate their efforts on attracting younger nurses, then providing opportunities for more flexible part-time work with some arrangements for children offers the greatest potential. Many would echo one respondent’s comment that “I do not feel recognised as a mother in the health service and that’s why my career came to a standstill”. The suggestions relating to school children not surprisingly found most support amongst respondents who had children aged 5-l 1, but that group was less concerned about creches
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Table 5. Attitudes to possible arrangements
R0BI.V
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for children, by age of youngest child (oio) Responding “very successful” Age of youngest child
Possible changes Part-time work opportunities Working time to suit the nurse Hours to fit schooling Time off when children ill C&he/nursery school Facilities for school children Total N
12-16
16+
No child
89 83 87 80 23 55
70 57 45 49 19 I5
67 59 26 26 18 22
50 46 26 23 30 21
127
53
99
146
o-4
5-11
a2 80 79 76 64 52 217
or nursery schools than the respondents with younger children (Table 5). Respondents with no children were, predictably, less enthusiastic about the suggestions concerning children and relatively more enthusiastic about the suggestions to do with general conditions of work and pay. Large differences in attitudes were apparent when the sample of respondents was divided into males and females. With the exception of better basic pay, all the suggestions received a more enthusiastic response from females than from males. In particular, the suggestions concerning flexible part-time work and those concerned with arrangements for children were strongly supported by a high proportion of women but a low proportion of men. The differences were significant, in spite of the small number of men in the sample. These results offer very little encouragement for measures to bring back male trained nurses into the service. One man pointed out that “I would need the basic pay to be greatly increased to support a family and mortgage for me to return to nursing”. A breakdown of respondents by qualification, on the other hand, revealed only small differences in attitudes. Whether or not the respondent was currently working in another job seemed to have a slight effect. Predictably, those with paid jobs were more likely to judge improvements in pay and promotion prospects as likely to be very successful in attracting them back to nursing than those without jobs (at the 0.05 level). Conversely, they were significantly less enthusiastic about suggestions of working hours to fit in with children’s schooling and time off when children are ill, compared with the group without paid jobs. But apart from these differences the responses from those working and those not working in paid jobs were remarkably similar. For both groups, flexible part-time work and a refresher course were the most attractive suggestions. The changes promising to be most successful in attracting trained nurses back into the service are thrown into sharper relief by focusing on those who consider themselves likely to return to nursing. Enthusiasm for most of the suggestions was significantly lower amongst those who thought their return was unlikely and higher amongst those who expected to return (Table 6). It is clear that recruitment efforts have the greatest chance of success if they concentrate on the latter group. Amongst the nurses who said they were likely to return, the two issues of primary importance were more opportunities for part-time work and working times to suit the individual. Third in importance was a refresher course. Next were hours to fit in with children’s schooling and time off when children are ill. Other factors, such as facilities for babies or children, better pay and better nurse/patient ratios were stongly supported, but their appeal was less than that of the major factors identified above.
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Table 6. Attitudes to possible changes by likelihood of return to nursing (olo) Responding “very successful” Likelihood of return Very Very Fairly Fairly unlikely likely unlikely likely 50
48 49 80 7-l 68 65 47 48 23 18 42 68 37
47 45 49 82 80 73 68 44 42 20 13 38 78 49
42 44 53 65 57 42 42 26 25 22 12 44 73 59
35 29 41 45 40 34 29 30 22 I9 16 35 60 5:
205
142
81
91
Better basic pay Pay for unsocial hours Improved nurse/patient ratios Part-time work opportunities Working time to suit the nurse Hours to fit schooling Time off when children ill Creche/nursery school Facilities for school children Transport Share job More senior posts Refresher course Trial period Total N
Discussion
The results reported here did not come from a random sample. It is not likely that the 642 former nurses who completed the questionnaire were representative of non-practising nurses generally. Those included in the survey had taken the trouble to complete and post two items, so the sample is expected to contain more people who are interested in maintaining contact with nursing and perhaps returning to the profession than the population of non-practising nurses as a whole. For an investigation of the factors most likely to be successful in bringing former nurses back to work, a bias towards the most highly motivated is a strength rather than a weakness. This investigation has confirmed that the findings of the national study conducted by OPCS in 1971 still hold. The most common reason for leaving nursing is still pregnancy. The majority of trained nurses not employed in nursing still express a wish to return to nursing at some time in the future, although the proportion appears to have fallen (from 64 per cent in the 1971 study to 54 per cent in the present enquiry). Given the probable bias towards enthusiastic respondents in our sample (which was not present in the OPCS survey), this 10 per cent reduction in the popularity of returning to nursing may well signal a real trend. The main barrier to recruitment remains the same. In 1971, as in this study, arrangements to enable mothers to look after their children while working part time were identified as the changes offering most potential for attracting former nurses back. While the overall situation may not have changed greatly since the OPCS survey 19 years ago, the present study has supplied details of the current scene in one part of the country. In the Norwich Health District, commitment to nursing and an interest in returning is highest shortly after leaving. Large numbers of nurses who wish to return to the profession have young children or other dependants to look after. Men, who tend to leave the service for other reasons, are less likely to plan to return. The higher proportion of nurses wishing to return who live outside the city is perhaps an indication of small untapped pools of labour away from the main centre of employment. The most surprising finding is that getting
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another job does not appear to diminish the intention of returning to nursing at some time in the future. It is the age of the youngest child which largely determines women’s availability for employment. Most former nurses with pre-school children indicated that a return in 2-5 years’ time was possible. Former nurses with older children were less inclined to wait, but fewer of them were interested in returning. There is little doubt that the key group with the highest probability of return is of young women who have recently left nursing in order to have children, According to their own assessments, the best time for them to resume nursing is shortly after the youngest child enters school. At present there are barriers that discourage this potentially large labour force from reentering the nursing profession. Pay and conditions of work must be taken into account, but these are less significant than the practical problems of doing a job and looking after children at the same time. The results of this survey indicate that the most promising course of action is to provide the opportunity for part-time work with hours to suit the individual concerned. In particular, the hours of work must make allowance for the demands made on mothers with children of school age. Such arrangements combined with a refresher course offer the best prospect of attracting large numbers of trained nurses back into the NHS. In the absence of an accurate national register, health authorities have a substantial problem in identifying the large numbers of non-practising nurses who live in their districts. A useful by-product of this research has been the establishment of a local register of nonpractising nurses. All nurses who leave NHS employment but who remain in the Norwich district from now on will be added to the register. It is planned to maintain contact with the nurses on the register by mailing a newsletter at regular intervals. The local register will be used to keep in contact with a potential workforce. At one level, a source of names and addresses will be valuable for circulating general information about vacancies and special arrangements as they become available. At a more detailed scale, the register could be used to focus on particular individuals: to contact, for instance, trained nurses with children who have reached a certain age or trained midwives living in a defined area. This will facilitate the more active recruitment strategy required for the 1990s. Acknowledgement-This study was funded by the Norwich Health Authority and was carried out in collaboration with the then Director of Nursing, Mr. R. Purcell. We are very grateful for his help.
References Dean, D. _I. (1987) hkrnpower Solurions. Royal College of Nursing, London. Institute of Manpower Studies (1985) TheManpower Implications ofPossible Changes in Basic Nurse Training. In Annexe of Research Studies for Commission on Nursing Education. Royal College of Nursing of the United Kingdom. Reid, N. G. (1986) Nurse manpower: the problems ahead. Int. J. Nurs. Stud. 23, 187-197. Sadler, J. and Whitworth, T. (1975) Reserves of Nurses, HMSO, London. Waite, R. and Hutt, R. (1987) Arfitudes, Jobs andMobility of Qualified Nurses. Institute of Manpower Studies Report No. 130, University of Sussex, Brighton. Waite, R., Buchan, J. and Thomas, J. (1989) NursesIn and Out of Work. Institute of Manpower Studies Report No. 170, University of Sussex, Brighton. (Received 13 September 1989; accepted for publication 23 February 1990)
