Abstract
Background
Social care staff shortages are having a detrimental impact across the health and care system. There are reports of care homes closing, stopping nursing services, and not admitting new residents because of challenges with staff shortages.
Aim
To develop an explanatory framework of strategies used to attract, recruit, and retain Registered Nurses (RNs) and care workers working in care homes. Explain how and why strategies work, for whom, the conditions needed, and the costs involved.
Design and methods
A realist synthesis approach was used. In step 1 strategies were identified and initial programme theories (IPTs) developed using data from stakeholder consultations (n=10), theory gleaning interviews with RNs and care workers (n=13), and evidence retrieved from scoping literature searches (n=50). Strategies (and IPTs) prioritised by sector stakeholders focused on staff recruitment and retention, and were taken forward for testing/refinement. Step 2 involved searching academic databases and social care websites for evidence. Step 3 involved screening and selecting records relevant to the prioritised IPTs. Relevant data were extracted and analysed to identify context-mechanism-outcome configurations. To assess rigour, the appropriateness of research methods, and the plausibility/transparency of grey literature were assessed. Step 4 involved testing and refining the IPTs, with programme theories sense checked/refined by sector stakeholders. Existing and established theories were used to help further explain the theories and develop an overarching explanatory framework.
Results
During step 1, strategies used to attract, recruit, and retain RNs and care workers were identified and IPTs developed (n=22). Ten IPTs were prioritised for testing/refining and were focused on recruitment and retention: staff recognition, flexible working, career development, salary package, early investment, induction, continuous feedback, caring community, effective interviewing, and listening to all staff.
From the focused literature searches 153 papers were included and data from these were used to test and refine the prioritised IPTs, and throughout the process collated into 5 final theories: effective interviewing, career development, reward and recognition, promoting work-life balance, and caring conversations. These strategies do not operate independently, they interact and work together. Effective interviewing sets accurate expectations, and loyalty starts to develop through setting an accurate ‘psychological contract’ which is fulfilled over time. Opportunities for career development, rewarding and recognising staff, providing flexible working options, and supporting staff with caring conversations helps staff to feel listened to, respected, and valued, which in turn, develops job satisfaction. Supportive leaders, and a sense of inclusion and fairness are needed for these strategies to work well. These strategies help to provide staff with positive experiences, and these are reciprocated through employee commitment and loyalty. Supporting staff through providing caring conversations and opportunities for career development also helps staff feel empowered.
Conclusions
This is the first realist synthesis in this field. The findings provide practical strategies for improving staff recruitment and retention.
Limitations
Stakeholder consultations did not include the views of staff who had left care work.
Future work
Understanding how to attract new staff to the social care workforce remains an important research gap.
Study registration
The review was registered as PROSPERO CRD42021261112.
Funding details
The project was funded by the National Institute for Health and Care Research (NIHR), Health Services and Delivery Research (HS&DR, reference NIHR131016).
Social care staff shortages are having a detrimental impact across the health and care system. There are reports of care homes closing, stopping nursing services, and not admitting new residents because of challenges with staff shortages.
Aim
To develop an explanatory framework of strategies used to attract, recruit, and retain Registered Nurses (RNs) and care workers working in care homes. Explain how and why strategies work, for whom, the conditions needed, and the costs involved.
Design and methods
A realist synthesis approach was used. In step 1 strategies were identified and initial programme theories (IPTs) developed using data from stakeholder consultations (n=10), theory gleaning interviews with RNs and care workers (n=13), and evidence retrieved from scoping literature searches (n=50). Strategies (and IPTs) prioritised by sector stakeholders focused on staff recruitment and retention, and were taken forward for testing/refinement. Step 2 involved searching academic databases and social care websites for evidence. Step 3 involved screening and selecting records relevant to the prioritised IPTs. Relevant data were extracted and analysed to identify context-mechanism-outcome configurations. To assess rigour, the appropriateness of research methods, and the plausibility/transparency of grey literature were assessed. Step 4 involved testing and refining the IPTs, with programme theories sense checked/refined by sector stakeholders. Existing and established theories were used to help further explain the theories and develop an overarching explanatory framework.
Results
During step 1, strategies used to attract, recruit, and retain RNs and care workers were identified and IPTs developed (n=22). Ten IPTs were prioritised for testing/refining and were focused on recruitment and retention: staff recognition, flexible working, career development, salary package, early investment, induction, continuous feedback, caring community, effective interviewing, and listening to all staff.
From the focused literature searches 153 papers were included and data from these were used to test and refine the prioritised IPTs, and throughout the process collated into 5 final theories: effective interviewing, career development, reward and recognition, promoting work-life balance, and caring conversations. These strategies do not operate independently, they interact and work together. Effective interviewing sets accurate expectations, and loyalty starts to develop through setting an accurate ‘psychological contract’ which is fulfilled over time. Opportunities for career development, rewarding and recognising staff, providing flexible working options, and supporting staff with caring conversations helps staff to feel listened to, respected, and valued, which in turn, develops job satisfaction. Supportive leaders, and a sense of inclusion and fairness are needed for these strategies to work well. These strategies help to provide staff with positive experiences, and these are reciprocated through employee commitment and loyalty. Supporting staff through providing caring conversations and opportunities for career development also helps staff feel empowered.
Conclusions
This is the first realist synthesis in this field. The findings provide practical strategies for improving staff recruitment and retention.
Limitations
Stakeholder consultations did not include the views of staff who had left care work.
Future work
Understanding how to attract new staff to the social care workforce remains an important research gap.
Study registration
The review was registered as PROSPERO CRD42021261112.
Funding details
The project was funded by the National Institute for Health and Care Research (NIHR), Health Services and Delivery Research (HS&DR, reference NIHR131016).
| Original language | English |
|---|---|
| Journal | Health and Social Care Delivery Research |
| DOIs | |
| Publication status | Accepted/In press - 11 Jul 2025 |
Keywords
- care home
- long term care
- social care
- workforce
- Registered nurse
- care worker
- recruitment and retention