Can improving work-life balance help tackle the nursing shortage?

Nursing has been highlighted as ‘the most urgent challenge’ in the Interim NHS People Plan. Our year-long pilot has focused on improving nurses’ work-life balance by addressing their working patterns. And it’s delivered three key recommendations to tackle the nursing shortage head-on.

It’s well-known that the NHS is struggling to find and keep enough staff, but the numbers relating to nursing shortages are no less shocking for their familiarity. Nurse resignations for poor work-life balance have increased by a staggering 169% between 2011-12 and 2017-18, according to analysis for the Labour party. And the Interim NHS People Plan notes that the organisation will need to recruit 40,000 extra nurses in the next five years just to stand still.

As we know from our work in other sectors, offering flexible working is a sure-fire way to improve work-life balance. But in a shift-based, skills-driven, 24-hour environment like an NHS ward, it’s complex to introduce. As a result, most wards operate on a two-tier system in which a few, fortunate individuals have an agreed flexible working arrangement (FWA), usually for childcare reasons. Everyone else then has to fit around them, with minimal input and even less predictability.

Why we chose to pilot a team-based approach to rostering

Over the last year, we have been supported by the Burdett Trust for Nursing to explore potential solutions for making work-life balance available for all, and not just those with a FWA.

Our belief was that by increasing the fit between nurses’ working pattern preferences and their actual working patterns, more of them would stay. At the same time, we were mindful that any solution would need to work within the KPIs and mix of skills that ward managers needed to deliver.

So, building on academic research, and following a series of focus groups with participating hospitals, we piloted a team-based approach to rostering , with the aim of increasing the amount of input that nurses have into their working patterns, whilst taking into account the operational constraints of life on the ward.

What the project involved

A sizeable piece of action research, this two-stage project involved 240 nurses in seven wards across three NHS trusts. We ran the first, six-month stage at Birmingham Women and Children’s Hospital (BWCH), and used our findings to inform the second stage at Nottingham University Hospitals (NUH) and University Hospital Southampton (UHS).

We began at BWCH by creating and training a lead team for each ward who were responsible for creating the roster (previously undertaken by the ward manager). Each lead team were allocated a subgroup of nurses and tasked with finding out their long-term preferences.

The lead team members then worked together to create the roster based on their colleagues’ input, making sure that unpopular shifts were spread fairly and that each shift had the right number of nurses with particular skills.

Following the completion of the first pilot at BWCH, we fed our learnings into the second six-month stage, across all three hospitals, and finished with a formal evaluation.

Three main benefits of team-based rostering and other findings

Our evaluation indicated that there were three main benefits to team-based rostering. A comparison of pre- and post-pilot data showed:

• the proportion of nurses who indicated that their preferences were being met ‘a lot’ or ‘fully’ increased from 39% to 51%
• the proportion who rated their input into the rosters as high went up from 14% to 26%
• the proportion who reported a strong sense of collective responsibility improved from 16% to 36%

Other important findings include: the critical role played by the ward manager in making the new approach work; the need to choose the lead team members carefully, to ensure the right balance of skills; and the extra time (and so budget) required to train the teams and deliver the roster.

Our calls for action at organisational and national level

Overall, then, we are cautiously positive about the potential of team-based rostering; indeed, the teams who worked with us are continuing to create their rosters in this way. However, there’s no question that more work is needed so that other teams and NHS Trusts can benefit from what we have learned. And, given that most of the guidelines on flexible working in the NHS are not adapted for shift-based roles, it’s also clear that bespoke definitions need to be developed.

We are therefore making the following recommendations to bring about widespread change:

• Trusts need to scale up the team-based approach as part of shared governance and shared decision-making initiatives. While there are costs involved in a team-based approach, these need to be seen in the context of the longer term benefits of work-life balance for staff attraction and retention.
• Policy makers such as NHSE/I need to redefine flexible working and work-life balance for the nursing profession and consider creating a national specification on how e-rostering systems can better meet nurses’ work-life needs. As part of this, e-rostering software suppliers could be asked to design rostering systems that better support the inclusion of nurses’ long-term work-life preferences.
• NHS Trusts need to offer better training and guidance on how to use the e-roster to create work-life balance, based on the definition changes suggested above, for nurses and other shift-based workers.

It won’t be a quick fix; these kind of changes take time, money and serious collaboration. But by taking action, we stand to gain a happier, healthier workforce who will stay within the NHS for longer. And given that nursing shortages are already at critical levels, there’s no time to waste.

Published September 2019