References

Applebaum D, Fowler S, Fiedler N, Osinubi O, Robson M The impact of environmental factors on nursing stress, job satisfaction, and turnover intention. J Nurs Adm. 2010; 40:(7/8)323-328 https://doi.org/10.1097/NNA.0b013e3181e9393b

Aveyard H Doing A Literature Review In Health And Social Care: A Practical Guide.Bucks: Open University Press; 2014

Aveyard H, Payne S, Preston N A Postgraduate's Guide To Doing A Literature Review In Health And Social Care.Bucks: Open University Press; 2016

Begley TM, Czajka JM Panel analysis of the moderating effects of commitment on job satisfaction, intent to quit, and health following organizational change. J Appl Psychol. 1993; 78:(4)552-556

Boamah S, Laschinger H Engaging new nurses: the role of psychological capital and workplace empowerment. J Res Nurs. 2015; 20:(4)265-277 https://doi.org/10.1177/1744987114527302

Braun V, Clarke V Thematic Analysis: A Practical Guide.London: Sage Publications Ltd; 2022

Brook J, Thurtle V, Murray J Building the English health visitor workforce as a result of the Health Visitor Implementation Plan 2011–2015: a survey study of career progression and retention for newly qualified health visitors. Prim Health Care Res Dev. 2019; 20 e128 https://doi.org/10.1017/S1463423619000604

Brookes K, Davidson P, Daly J, Hancock K Community health nursing in Australia: A critical literature review and implications for professional development. Contemp Nurse. 2004; 16:(3)195-207 https://doi.org/10.5172/conu.16.3.195

Cai C, Zhou Z Structural empowerment, job satisfaction, and turnover intention of Chinese clinical nurses. Nurs Health Sci. 2009; 11:(4)397-403 https://doi.org/10.1111/j.1442-2018.2009.00470.x

Chang HY, Chu TL, Liao YN, Chang YT, Teng CI How do career barriers and supports impact nurse professional commitment and professional turnover intention?. J Nurs Manag. 2019; 27:(2)347-356 https://doi.org/10.1111/jonm.12674

Rebuilding the Health Visiting Workforce: Costing Policy Proposals. 2021. https://dl.orangedox.com/HVCosting (accessed 5 November 2024)

Qualitative Data Coding 101: How to code qualitative data, the smart way (with examples). 2020. https://gradcoach.com/qualitative-data-coding-101/ (accessed 5 November 2024)

Cutcliffe J, McFeely S Practice nurses and their ‘lived experience’ of clinical supervision. Br J Nurs. 2001; 10:(5)312-323 https://doi.org/10.12968/bjon.2001.10.5.5359

Department of Health. Health Visitor Implementation Plan 2011–15: A Call to Action. 2011. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124208.pdf (accessed 5 November 2024)

Equality Analysis: Health Visiting Programme.London: DH; 2012

Dominguez D, Chambel MJ, Carvalho VS Enhancing Engagement through Job Resources: The Moderating Role of Affective Commitment. Span J Psychol. 2020; 23

Donald IAN, Siu OL Moderating the stress impact of environmental conditions: the effect of organizational commitment in Hong Kong and China. J Environ Psychol. 2001; 21:(4)353-368 https://doi.org/10.1006/jevp.2001.0229

Drennan VM, Halter M, Gale J, Harris R Retaining nurses in metropolitan areas: insights from senior nurse and human resource managers. J Nurs Manag. 2016; 24:(8)1041-1048

Duffield C, Roche M, O'Brien-Pallas L, Catling-Paull C, King M Staff satisfaction and retention and the role of the Nursing Unit Manager. Collegian. 2009; 16:(1)11-17 https://doi.org/10.1016/j.colegn.2008.12.004

Duffield C, Baldwin R, Roche M, Wise S Job enrichment: creating meaningful career development opportunities for nurses. J Nurs Manag. 2014; 22:(6)697-706 https://doi.org/10.1111/jonm.12049

Fineout-Overholt E, Johnston L Teaching EBP: asking searchable, answerable clinical questions. Worldviews Evid Based Nurs. 2005; 2:(3)157-60

Fletcher JK The paradox of postheroic leadership: an essay on gender, power, and transformational change. Leadersh Q. 2004; 15:(5)647-661 https://doi.org/10.1016/j.leaqua.2004.07.004

Forde-Johnston C, Stoermer F Giving nurses a voice through ‘listening to staff’ conversations to inform nurse retention and reduce turnover. Br J Nurs. 2022; 31:(12)632-638

Goodloe LR, Sampson RC, Munjas B, Whitworth TR, Lantz CD, Tangley E, Miller W Clinical ladder to professional advancement program. An evolutionary process. J Nurs Adm. 1996; 26:(6)58-64 https://doi.org/10.1097/00005110-199606000-00016

Gender equality at every stage: a roadmap for change.London: Government Equalities Office; 2018

Greenhalgh T, Peacock R Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources. BMJ. 2005; 331:(7524)1064-1065 https://doi.org/10.1136/bmj.38636.593461.68

Guerrero S, Chênevert D, Kilroy S ‘New graduate nurses' professional commitment: antecedents and outcomes’. J Nurs Scholarsh. 2017; 49:(5)572-579 https://doi.org/10.1111/jnu.12323

Guo J, Chen J, Fu J, Ge X, Chen M, Liu Y Structural empowerment, job stress and burnout of nurses in China. Appl Nurs Res. 2016; 31:41-45 https://doi.org/10.1016/j.apnr.2015.12.007

Harms PD, Vanhove A, Luthans F Positive projections and health: an initial validation of the implicit psychological capital health measure. Appl Psychol. 2017; 66:(1)78-102 https://doi.org/10.1111/apps.12077

Heilman ME, Block CJ, Martell RF, Simon MC Has anything changed? Current characterizations of men, women, and managers. J Appl Psychol. 1989; 74:(6)935-942 https://doi.org/10.1037/0021-9010.74.6.935

Hemstrom M, Ambrose M, Donahue G, Glick L, Lai HL, Preechawong S The clinical specialist in community health nursing: a solution for the 21st century. Public Health Nurs. 2000; 17:(5)386-391

Hochschild AR The Managed Heart, Twentieth Anniversary Edition. : University of California Press Ltd; 2003

Women Rising: The Unseen Barriers. 2013. https://hbr.org/2013/09/women-rising-the-unseen-barriers (accessed 5 November 2024)

Institute of Health Visiting. Building a Future: A Career Pathway in Health Visiting. 2023. https://ihv.org.uk/news-and-views/news/building-a-future-a-career-pathway-in-health-visiting (accessed 5 November 2024)

Jafari F, Salari N, Hosseinian-Far A, Abdi A, Ezatizadeh N Predicting positive organizational behavior based on structural and psychological empowerment among nurses. Cost Eff Resour Alloc. 2021; 19:(1) https://doi.org/10.1186/s12962-021-00289-1

Kallio H, Kangasniemi M, Hult M Registered nurses' perceptions of their career—an interview study. J Nurs Manag. 2022; 30:(7)3378-3385 https://doi.org/10.1111/jonm.13796

Kanter RM Men and Women of the Corporation.New York, NY: Basic Books; 1977

Laschinger HK, Finegan J, Shamian J The impact of workplace empowerment, organizational trust on staff nurses' work satisfaction and organizational commitment. Health Care Manage Rev. 2001a; 2;26:(3)7-23 https://doi.org/10.1097/00004010-200107000-00002

Laschinger HKS, Finegan J Using empowerment to build trust and respect in the workplace: a strategy for addressing the nursing shortage. Nurs Econ. 2005; 23:(1)6-13

Laschinger HK, Wilk P, Cho J, Greco P Empowerment, engagement and perceived effectiveness in nursing work environments: does experience matter?. J Nurs Manag. 2009; 17:(5)636-646 https://doi.org/10.1111/j.1365-2834.2008.00907.x

Luthans F, Broad JD Positive psychological capital to help combat the mental health fallout from the pandemic and VUCA environment. Organ Dyn. 2022; 51:(2) https://doi.org/10.1016/j.orgdyn.2020.100817

Maben J Employee engagement and retention in the nursing workforce: A case study of an inner-London acute trust.London: King's College and London School of Hygiene and Tropical Medicine; 2008

Martin PD, Hutchinson SA Negotiating symbolic space: strategies to increase NP status and value. Nurse Pract. 1997; 22:(1)89-103 https://doi.org/10.1097/00006205-199701000-00006

Marufu TC, Collins A, Vargas L, Gillespie L, Almghairbi D Factors influencing retention among hospital nurses: systematic review. Br J Nurs. 2021; 30:(5)302-308

Mayes CG, Cochran K Factors Influencing Perioperative Nurse Turnover: A Classic Grounded Theory Study. AORN J. 2023; 117:(3)161-174 https://doi.org/10.1002/aorn.13880

McClure ML, Poulin MA, Sovie MD Magnet hospitals. Attraction and retention of professional nurses. Task Force on Nursing Practice in Hospitals. American Academy of Nursing. ANA Publ. 1983; (G-160)i-xiv

Meyer JP, Allen NJ A three-component conceptualization of organizational commitment. Hum Resour Manage Rev. 1991; 1:(1)61-89 https://doi.org/10.1016/1053-4822(91)90011-Z

Meyer J, Allen N Commitment in the Workplace: Theory, Research and Application.London: Sage; 1997

NHS Digital. Narrowing of NHS gender divide but men still the majority in senior roles. 2018. https://digital.nhs.uk/news/2018/narrowing-of-nhs-gender-divide-but-men-still-the-majority-in-senior-roles (accessed 5 November 2024)

NHS Employers. Developing staff career pathways to support workforce supply. 2022. https://www.nhsemployers.org/articles/developing-staff-career-pathways-support-workforce-supply (accessed 5 November 2024)

NHS Employers. ‘Growing your own’ – a focus on internal staff development to grow the workforce. 2023. https://www.nhsemployers.org/articles/growing-your-own-focus-internal-staff-development-grow-workforce (accessed 5 November 2024)

NHS England. NHS Long Term Workforce Plan. 2023a. https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf (accessed 5 November 2024)

NHS England. Gender pay gap report 2022: A combined report for NHS England and NHS Improvement. 2023b. https://www.england.nhs.uk/long-read/gender-pay-gap-report-2022/#:~:text=As%20of%2031%20March%202022%2C%20NHS%20England%20and%20NHS%20Improvement%27s,compared%20to%20the%20previous%20year (accessed 5 November 2024)

Nursing Notes. Health visitors in Scotland to be paid Band 7. 2021. https://nursingnotes.co.uk/news/workforce/health-visitors-in-scotland-to-be-paid-band-7/#google_vignette (accessed 5 November 2024)

Office for National Statistics. Gender pay gap in the UK. 2018. https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/earningsandworkinghours/bulletins/genderpaygapintheuk/2018 (accessed 5 November 2024)

Parastar F, Sepasi H, Noorbakhsh P The relationship between job analysis and job characteristics, psychological and structural empowerment: a model for the work environment of sports employees. J Sport Manag Movement Sci. 2014; 5:(3 and 4)25-35

Autonomy: a pillar of success. 2022. https://www.bps.org.uk/psychologist/autonomy-pillar-success (accessed 5 November 2024)

Powell GN, Butterfield DA The glass ceiling: what have we learned 20 years on?. Journal of Organizational Effectiveness: People and Performance. 2015; 2:(4)306-326 https://doi.org/10.1108/JOEPP-09-2015-0032

Punshon G, Maclaine K, Trevatt P, Radford M, Shanley O, Leary A Nursing pay by gender distribution in the UK - does the Glass Escalator still exist?. Int J Nurs Stud. 2019; 93:21-29

Rimmer A Five facts on women in NHS leadership roles. BMJ. 2017; 357 https://doi.org/10.1136/bmj.j1701

Roth C, Wensing M, Breckner A, Mahler C, Krug K, Berger S Keeping nurses in nursing: a qualitative study of German nurses' perceptions of push and pull factors to leave or stay in the profession. BMC Nurs. 2022; 21:(1) https://doi.org/10.1186/s12912-022-00822-4

Royal College of Nursing. Strategy to recruit more men into the nursing profession. 2018. www.rcn.org.uk/congress/agenda/male-nurses (accessed 5 November 2024)

Schein VE A global look at psychological barriers to women's progress in management. J Soc Issues. 2001; 57:(4)675-688 https://doi.org/10.1111/0022-4537.00235

Female misogyny-It's a thing. 2022. https://www.linkedin.com/pulse/female-misogyny-its-thing-patricia-seabright/ (accessed 5 November 2024)

Seller-Boersma A, Boot C, van Oostveen C, Jongerden I, van Vugt M Perspectives on Nurse Retention in Hospitals in the Netherlands: A Qualitative Study. Journal of Nursing Management. 2023; https://doi.org/10.1155/2023/1390591

Qualitative Study. 2022. https://www.ncbi.nlm.nih.gov/books/NBK470395/ (accessed 5 November 2024)

The Health Foundation, The King's Fund, Nuffield Trust. The health care workforce in England. 2018. https://www.kingsfund.org.uk/sites/default/files/2018-11/The%20health%20care%20workforce%20in%20England.pdf (accessed 5 November 2024)

Watkins M, Nicole Smith A Importance of women's political skill in male-dominated organizations. J Manag Psychol. 2014; 29:(2)206-222 https://doi.org/10.1108/JMP-06-2012-0106

Weyman AK, Roy D, Nolan P One-way pendulum?. Int J Workplace Health Manag. 2019; 13:(1)45-60 https://doi.org/10.1108/IJWHM-06-2019-0084

Whittaker K, Grigulis A, Hughes J Start and Stay: The Recruitment and Retention of Health Visitors.London: National Nursing Research Unit; 2013

Whittaker KA, Malone M, Cowley S, Grigulis A, Nicholson C, Maben J Making a difference for children and families: an appreciative inquiry of health visitor values and why they start and stay in post. Health Soc Care Community. 2017; 25:(2)338-348 https://doi.org/10.1111/hsc.12307

Woolnough H, Fielden S, Crozier S, Hunt C A longitudinal investigation of the glass-ceiling in nursing. J Manag Psychol. 2019; 34:(2)96-109 https://doi.org/10.1108/JMP-02-2018-0093

Zhu H, Xu C, Jiang H, Li M A qualitative study on the experiences and attributions for resigned nurses with career plateau. Int J Nurs Sci. 2021; 8:(3)325-331 https://doi.org/10.1016/j.ijnss.2021.05.006

Career progression opportunities and the retention of health visitors

02 November 2024
Volume 1 · Issue 3

Abstract

There is a shortage of health visitors in England and career progression is known to increase staff retention in nursing. Therefore, a systematic search strategy was conducted and four main themes emerged following a reflexive thematic analysis. It found career progression opportunities improve staff retention, while barriers to career progression, including a lack of structured career pathways and progression opportunities, staff shortages, unavailable funding for staff training and gender inequalities, have a negative impact on staff retention. It is concluded that providing structured career pathways could improve the retention of health visitors. Further research examining the influencing factors on health visitor retention is recommended. Structured career pathways should be offered, allocating time during working hours for health visitors to attend courses and work on projects, and ensure that equality, diversity and inclusion policies include specific strategies for female career progression.

The health visiting workforce in England has reduced by approximately 40% since 2015 (Mayes and Cochran, 2022; NHS Digital, 2022) with a shortfall of around 5000 health visitors (Conti and Dow, 2021). Many London NHS Trusts also report struggling to recruit into the specialist community public health nursing (SCPHN) programme (Institute of Health Visiting [iHV], 2023). Both these factors have a detrimental impact on client safety and experience.

The NHS Long Term Workforce Plan promotes staff retention initiatives to support adequate staffing across all areas of healthcare (NHS England, 2023a). As research identifies the strong influence that career progression opportunities have on staff retention, this literature review aimed to investigate the relationship between career progression and the retention of health visitors.

Rationale

Adequate staffing is crucial for the NHS to deliver a healthcare service that meets the growing needs of the population (NHS England, 2023a). The Health Foundation (2018) reported that between 2017 and 2018 there was minimal growth in workforce numbers in nursing and health visiting at just 0.5% and that there have been no improvements in staff retention since their 2011/2012 report (The Health Foundation et al, 2018). Staff shortages are found to be the strongest driver behind leaving the NHS (Weyman et al, 2019) and for health visitors, staff shortages result in higher caseloads, factors known to negatively affect staff wellbeing (Hochschild, 2003).

Creating working environments that support the growth of employees who are committed to their organisations is vital as they are more likely to remain with their organisation than those who are uncommitted (Meyer and Allen, 1991), a feature known as ‘affective commitment’ that is strongly associated with increased job satisfaction (Meyer et al, 1997) and empowerment (Laschinger et al, 2001). Organisations that provide staff with opportunities to progress and promote empowerment have increased job satisfaction (Laschinger et al, 2001; 2009; Laschinger and Finegan, 2005; Cai and Zhou, 2009). Autonomy is considered a natural byproduct of becoming empowered and forms a significant aspect of an individual's psychological wellbeing (Perry, 2022). Therefore, organisations that can support the growth of empowered and autonomous practitioners position themselves more competitively when recruiting and retaining staff.

However, job satisfaction is a major factor in nurses' intention to stay in their roles and their profession (Duffield et al, 2009; Applebaum et al, 2010). A seminal study undertaken by McClure et al (1983) looked at specific characteristics that attracted nursing staff to organisations with high rates of retention and recruitment. They found that ‘magnet’ hospitals offered competitive salaries and benefits, opportunities for promotion, and professional and career development (McClure et al, 1983). A 2021 systematic review exploring factors that influenced retention of hospital nurses also found adequate staffing and career progression opportunities to be key influential factors (Marufu et al, 2021).

Evidence suggests that health visitors leave the profession to pursue new roles for a number of reasons – one of which is the opportunity to progress their career and achieve a higher salary (Brook et al, 2019). In 2018, Scottish healthcare unions successfully negotiated a new pay band with a corresponding salary for the health visiting workforce (Royal College of Nursing [RCN], 2019; Nursing Notes, 2021). As well as recognising the value that health visitors add by undertaking their role, this development was implemented in the hope that it would make health visiting a more attractive role, improving recruitment and retention (Nursing Notes, 2021).

The iHV has recently published a suggested career pathway in health visiting, which includes leadership roles for advanced health visitor practitioners and health visitor consultants/clinical academics/senior leaders, to attract more people into the profession and to retain staff wanting to progress to more senior roles (iHV, 2023). As health visiting is a female-dominated workforce (NHS Digital, 2018), the relevance of the gender pay gap and disparities between male and female career progression is an important consideration.

The Health Foundation (2018) highlights the negative impact that inequalities in gender, ethnicity and occupations have on recruitment, pay and career progression. Its report on the gender pay gap and career advancement disparity between men and women in the NHS found there was a 77% female workforce and an 8.6% pay gap in favour of men (The Health Foundation et al, 2018). In the context of the UK as a whole, the gender pay gap is 17.9% (Office for National Statistics, 2018) and a drive was launched in 2018 to close this gap and reduce inequality (Government Equalities Office, 2018).

Methodology

A population, intervention, comparison, outcome (PICO) table (Table 1) was used to formulate the research question as recommended by Fineout-Overholt and Johnston (2005) and Aveyard (2014). The following research question resulted from undertaking the processes described: ‘What is the relationship between career progression opportunities and the retention of health visitors?’.


PICO Description
Population Specialist community public health nurses (health visitors)
Issue Staffing shortfalls of health visitors in England affecting service provision for children and families
Context Staff shortfalls in health visiting and difficulty recruiting on to the SCPHN programme
Outcome To understand the relationship between career progression opportunities and health visitor retention, to identify gaps in knowledge and opportunities for further research

The university's library search engine, which accesses a wide range of academic databases (Aveyard, 2014) including Internurse, CINAHL, MEDLINE and PubMed, was used to search for literature. A snowballing technique, hand searching relevant journals, author searching and searching reference lists further enhanced this literature search (Greenlaugh and Peacock, 2005; Aveyard, 2014) (Box 1). All papers were screened for their relevance and in accordance with the inclusion and exclusion criteria. Table 2 illustrates the electronic search strategy used including Boolean operators and truncations (Aveyard, 2014).

Key words

  • Career development
  • Career progression
  • Career advancement
  • Aspirations
  • Retention
  • Staff retention
  • Health visitor
  • Health visiting
  • Community nurse
  • SCPHN
  • Specialist community public health nurse
  • Nursing
  • Healthcare professional

  • Database Hits Studies identified
    University Library Advanced Search 1 “career development” AND retention OR “staff retention” AND nurs* OR nursing OR “healthcare professional” 298 Duffield et al, 2014 Kallio et al, 2022 Woolnough et al, 2018Roth et al, 2022Drennan et al, 2016Mayes et al, 2023Zhu et al, 2021
    University Library Advanced Search 2 “career development” OR “career progression” OR aspirations AND retention OR “staff retention” AND nurs* OR nursing OR “healthcare professional” OR “health visitor*” OR “health visiting” OR SCPHN 416 Whitakker et al, 2017 Brook et al, 2019 Whitaker, 2013
    Internurse career development” OR “personal development” AND retention OR “staff retention” AND “health visitor” OR “health visiting” OR SCPHN 928 Brook et al, 2023Forde-Johnston and Stoermer, 2022

    Inclusion and exclusion criteria

    The criteria used are detailed in Table 3 and denote both pragmatic choices such as time frames, as well as choices influencing the type of data to meet the review aims. As background reading, which included reviewing various quantitative papers, established that career progression is associated with retention of nursing staff and is a key factor in ‘magnetising’ staff to organisations (McClure et al, 1983), it was decided that focusing this literature review on qualitative data would better suit the aim of this investigation.


    Inclusion criteria Exclusion criteria
    Date range: last 10 years Studies older than 10 years
    Peer reviewed Non-peer reviewed
    Primary research Systematic reviews
    Qualitative studies Quantitative studies
    Studies looking at career progression in relation to either retention or attrition
    Study samples including health visitors, nurses, community nurses, district nursing and/or student nurses Studies on midwives and nursing associates

    Due to a lack of research on the retention of health visitors, 80% of the included studies are based on cohorts from various nursing disciplines both in and outside of the UK. However, as health visitors are all qualified nurses or midwives by background, the perceptions of nurses were considered relevant in this literature review. Comparisons between health visitors and other nursing disciplines have been drawn previously due to similar motivations to perform their role (Maben, 2008). However, it is recognised that further research on health visitors' perceptions would improve knowledge of their specific experience of career progression.

    Critical appraisal of the research

    A Critical Appraisal Skills Programme (CASP) tool to identify the strengths and weaknesses of each paper was used (Aveyard et al, 2016).

    Analysis and synthesis

    A reflexive thematic analysis was considered the most appropriate method to interpret the data. This style has six recommended phases to support the identification and interpretation of patterns across the included papers (Braun and Clarke, 2022). The strength of this method is in its use of a good coding technique (Braun and Clark, 2022); therefore, the inductive coding method was chosen (Crossly, 2020).

    The research was interpreted to seek new meaning and themes generated through the process of meta-synthesis (Aveyard et al, 2016). This involved reading through the data many times over a period of months, resulting in the organic formation of an appreciation for the essence of the data.

    Themes

    Career progression opportunities support staff retention

    Researchers measured differences in nurses' affective commitment in several South Australian healthcare facilities implementing a work enrichment policy providing career pathways, and opportunities to participate in strategic projects (Duffield et al, 2014). Involvement in the programme was associated with increased motivation and job satisfaction and, therefore, increased affective commitment (Duffield et al, 2014).

    Senior managers from a number of south London NHS Trusts, an area known to have increased staff attrition rates (Drennan et al, 2016), articulated that Trusts should think competitively in workforce planning. They asserted that any staff retention strategies must consider magnetic factors that give them an advantage in the job market. They went on to identify that offering career progression opportunities increases an organisation's attractiveness (Drennan et al, 2016).

    A mixed-methods study conducted by Brook et al (2019) following the Health Visitor Implementation Plan (Department of Health, 2011) found that health visitors leave their roles to pursue career progression opportunities. The free-text responses provided some insight into why health visitors leave their roles; however, the quality was reduced due to the data being collected via electronic survey, so responses were not explored in more depth. The researchers also acknowledged that due to the chosen data collection method generating a 19% response rate, a non-response bias may have limited the validity of the results. However, a key recommendation from this study was that career pathways should be implemented to retain health visitors (Brook et al, 2019).

    A study of nurses' perceptions of their careers found that they linked career development with increased competence, independence, influence and meaningful working life experience (Kallio et al, 2022). The researchers reported that, while participants felt nursing is a meaningful and compassionate career, in order for motivation to be sustained, feeling challenged is essential. The authors concluded that career development opportunities would increase career engagement and increase the attractiveness of nursing (Kallio et al, 2022).

    A large research project commissioned by the Department of Health in England included a study of the recruitment and retention of health visitors to inform and support the Health Visitor Implementation Plan (Whittaker et al, 2013). A key aim was to understand the factors that support health visitor job satisfaction and retention. The research identified that health visitors are motivated by feeling challenged, with the clinical practice teacher (CPT) increasing motivation due to adding more variety, career progression and purpose to the health visitor role (Whittaker et al, 2013).

    A longitudinal study comprising a study group and a control group on female mental health nurses' experiences of the ‘glass ceiling’ in the NHS found that empowered workforces seek progression. The glass ceiling refers to unseen obstacles preventing women and other disadvantaged groups from progressing into senior leadership positions (Watkins and Smith, 2014; Powell and Butterfield, 2015). Its existence is present even in female-dominated occupations such as nursing (Powell and Butterfield, 2015; RCN, 2018).

    Woolnough et al (2019) conducted semi-structured interviews at three time periods over 12 months and found that participants' awareness of the existence of the glass ceiling increased and led to intrinsic changes that were felt as a process of empowerment. A high proportion of participants who were promoted during the study secured more senior positions outside of the NHS in comparison to the control group (Woolnough et al, 2019), highlighting how a lack of career progression opportunities reduce affective commitment and risks the loss of highly skilled and motivated employees.

    Overview of included studies

  • Brook J, Thurtle V, Murray J. Building the English health visitor workforce as a result of the Health Visitor Implementation Plan 2011-2015: a survey study of career progression and retention for newly qualified health visitors. Prim Health Care Res Dev. 2019 Sep 9;20:e128
  • Drennan VM, Halter M, Gale J, Harris R. Retaining nurses in metropolitan areas: insights from senior nurse and human resource managers. J Nurs Manag. 2016 Nov;24(8):1041-1048
  • Duffield C, Baldwin R, Roche M, Wise S. Job enrichment: creating meaningful career development opportunities for nurses. J Nurs Manag. 2014 Sep;22(6):697-706
  • Forde-Johnston C, Stoermer F. Giving nurses a voice through ‘listening to staff’ conversations to inform nurse retention and reduce turnover. Br J Nurs. 2022 Jun 23;31(12):632-638
  • Kallio H, Kangasniemi M, Hult M. Registered nurses' perceptions of their career-An interview study. J Nurs Manag. 2022 Oct;30(7):3378-3385
  • Mayes CG, Cochran K. Factors Influencing Perioperative Nurse Turnover: A Classic Grounded Theory Study. AORN J. 2023 Mar;117(3):161-174
  • Roth C, Wensing M, Breckner A, Mahler C, Krug K, Berger S. Keeping nurses in nursing: a qualitative study of German nurses' perceptions of push and pull factors to leave or stay in the profession. BMC Nurs. 2022 Feb 23;21(1):48
  • Whittaker K, Grigulis A, Hughes J, Cowley S et al. Start and Stay: The Recruitment and Retention of Health Visitors. London: National Nursing Research Unit; 2013
  • Woolnough H, Fielden S, Crozier S, Hunt C. A longitudinal investigation of the glass-ceiling in nursing. Journal of Managerial Psychology. 2019;34(2):96-109
  • Zhu H, Xu C, Jiang H, Li M. A qualitative study on the experiences and attributions for resigned nurses with career plateau. Int J Nurs Sci. 2021 May 31;8(3):325-331
  • Researchers found that health visitors place value on autonomy, reporting that the more autonomous they feel, the greater their ability to make a difference to families (Whittaker et al, 2013). While this study did not necessarily explore the impact of career progression on autonomy specifically, it confirmed that autonomy is valued. Kallio et al (2022) added insight into this as they ascertained that nurses are motivated by development opportunities as it empowers them to increase their competence which leads to greater autonomy.

    The Woolnough et al (2019) study illustrated that empowering individuals through education simultaneously develops their sense of autonomy, as those in the control groups were more likely to attribute their lack of career progression to situations out of their control, such as feeling as though their careers were influenced by whether or not their ‘faces fit’ in the organisation. This reflects the disempowering impact that a lack of awareness around inequalities in female career progression has. It is concerning as, over time, this sense of having a lack of control over one's career gradually reduces motivation, staff wellbeing and job performance (Perry, 2022).

    Supportive leadership and colleagues

    Drennan et al (2016) investigated factors influencing the retention of nurses by seeking views of senior managers across seven NHS Trusts in London. Many of the participants associated staff attrition with poor line management and it was recognised that the creation of opportunities for listening to staff and subsequently supporting them to seek solutions is important (Drennan et al, 2016).

    Zhu et al (2021) sought to understand the experiences of nurses who resigned from their roles due to career plateau. Although a limited recruitment strategy was used, the research provides insight into the feelings experienced by those unable to progress. Unsupportive leaders who did not encourage career progression translated to participants that they were not valued by their organisations, which had a disempowering effect (Zhu et al, 2021). Nurses in this study reported that a lack of progression led them to resign from their positions (Zhu et al, 2021), highlighting the importance of leadership encouraging those who want to progress to do so.

    Mayes et al (2023) found that staff are more likely to leave their roles if their career progression is not supported. Poor management was identified as a significant ‘push factor’ due to its detrimental impact on team cultures and holding people back from developing and reaching their potential (Mayes et al, 2023).

    Forde-Johnston and Stoermer (2022) conducted ‘listening to staff’ events (L2S) over 3 years to inform a nurse retention strategy in one UK hospital. They investigated nurses' perspectives of teamworking, support and career plans based on existing evidence of staff attrition and found that tailored, individualised support that includes career planning and providing career pathways improved staff retention.

    Staff supported by their managers to engage in non-client-facing activities to develop personal development are important, as Duffield et al (2014) established, with Kallio et al (2022) reporting on how they can be viewed as an expression of recognising potential. Participants in the Whittaker et al (2013) study articulated that a manager they held in high esteem was regarded as so because they rewarded individual health visitors' efforts with development opportunities. Kallio et al (2022) also identified that an organisation's attitude towards staff development and progression was reflected by the visibility of opportunities and whether staff were supported to access these in a meaningful way, such as being given allocated study time during working hours and at the employer's expense, for example (Kallio et al, 2022).

    Woolnough et al (2019) identified that female career progression is hindered by unsupportive colleagues with reference to female misogyny, a phenomenon associated with the persistence of the glass ceiling (Woolnough et al, 2019). Participants discussed how female co-workers and managers displayed resistant attitudes towards them, described as a ‘backlash’ (Woolnough et al, 2019). The most resistance was perceived to be aimed towards those who experienced the most rapid promotions (Woolnough et al, 2019). Participants described resistant females as ‘queen bees’ and discussed their behaviour as being protective of their own roles, which was construed as concern that the advancement of others would threaten their position (Woolnough et al, 2019). These perceptions were not held by those in the control group (Woolnough et al, 2019) and this implies that its existence is only felt when female nurses attempt to advance their careers.

    Supportive leaders and colleagues were identified as crucial to the successful career progression of individuals by Kallio et al (2022). Participants discussed the support mechanisms required to facilitate individuals to fully embrace opportunities, including having the respect from colleagues for experience and expertise, managers ensuring that development opportunities are promoted and ensuring that nurses are allocated time to study during working time and at the employer's expense. Participants also discussed how managers need to encourage nurses to apply for new opportunities by coaching them effectively to follow the path that is right for them (Kallio et al, 2022). Roth et al (2022) found that unsupportive working environments are disempowering for individuals and increases staff turnover.

    Feeling valued and recognised

    Duffield et al (2014) found that organisations that invest in career progression are perceived by participants, as valuing their staff. There is a general sense throughout the research that nurses both want and need to feel as though they are valued as individuals but also for the contribution they make to society (Zhu et al, 2021; Mayes et al, 2023). Feeling valued and respected is identified as increasing health visitors' job satisfaction, whereas feeling undervalued is the most prominent issue contributing to a reduction in their job satisfaction (Whittaker et al, 2013). Health visitors discussed the positive impact on morale of ‘away days’ focused on staff development (Whittaker et al, 2019), as they demonstrate an investment in them as individuals. In contrast, Zhu et al (2021) found that staff who feel unsupported to progress report a sense of worthlessness and feeling as though they are seen as ‘just a number’. A lack of investment in staff development was linked to staff feeling disempowered as they have less certainty about their future and are powerless to change their situation (Zhu et al, 2021).

    Nurses and health visitors have a deep sense of pride in the roles that they do, which is often used as a justification for their poor salaries and working conditions (Whittaker et al, 2013; Roth et al, 2022; Kellio et al, 2022). However, nurses consistently report that a general lack in society's recognition of the value in the nurse's role makes them feel lower in status (Roth et al, 2022). Salaries incompatible with the cost of living contribute to nurses feeling discriminated against. Woolnough et al (2019) support this perception that the existence of a glass ceiling is detrimental to female career progression.

    Brook et al (2019) identified that most health visitors leaving the role went to pay Band 7 roles elsewhere. Approximately 89% of health visitors participating in the study were at Band 6 and most of the study participants left the profession 1–2 years after qualifying, citing that pay as well as opportunities to progress were a key factor in this decision (Brook et al, 2019). Student health visitors discuss that post-qualifying salary does not necessarily equate to a pay rise, which makes them doubt their decision to undertake the SCPHN training and question the value in undertaking the 12-month programme for no financial gain (Woolnough et al, 2013).

    Nurses are reported to perceive that society views caring roles as vocational and believes that nurses should be humble in nature and content with their working conditions (Kallio et al, 2022).

    Researchers found that, although nurses are driven by intrinsic motivators in their work, factors such as long working hours and low salaries reduce morale as they reflect society's general lack of appreciation for the nursing role (Drennan et al, 2016; Brook et al, 2019; Forde-Johnston and Stoermer, 2022; Kallio et al, 2022; Roth et al, 2022; Mayes et al, 2023; Whittaker et al, 2013).

    Health visitors discuss the demoralising impact of other professionals' as well as the general public's lack of insight into their role, while nurses identify that raising awareness of the complexity of the nursing role would increase recognition and, therefore, the value that the public attaches to nurses, which may influence pay scales (Roth et al, 2022).

    Barriers to progression have a negative impact on staff retention

    Career progression is associated with an overall sense of struggle (Zhu et al, 2021; Roth et al, 2022). Participants reported that obtaining qualifications feels irrelevant for progression as they do not necessarily lead to promotion (Roth et al, 2022). Kallio et al (2022) reported that a lack of career pathways and opportunities limited nursing education, research or management while participants want opportunities to progress into roles that include direct patient care as this is where they get a sense of personal fulfilment (Kallio et al, 2022). Health visitors also report that progression options are limited to education or management (Whittaker et al, 2013).

    Several studies report a lack of career progression opportunities (Whittaker et al, 2013; Woolnough et al, 2019; Zhu et al, 2021; Roth et al, 2022; Kallio et al, 2022). Roth et al (2022) found that this is associated with unmotivated staff (Roth et al, 2022), while Whittaker et al (2013) reported how motivated health visitors are by career progression into a Band 7 CPT role. Zhu et al (2021) reported that career stagnation due to a lack of opportunities results in staff feeling as though they are unable to achieve their goals. Woolnough et al (2019) associated a lack of promotion opportunities with prompting NHS nurses to look for employment in other organisations. Indeed, Brook et al (2019) found that one of the most prominent reasons given for health visitors leaving their roles was to pursue career progression opportunities elsewhere.

    Staff wellbeing improved during participation in a career enrichment policy whereby improvements were found in motivation, job satisfaction and staff feeling empowered (Duffield et al, 2014). These results were achieved due to protected time being honoured to complete project-based work, which can only be granted where client-facing care is not compromised by reduced staffing levels. Therefore, the indirect impact of short staffing is the lack of flexibility in staffing to support non-client-facing activities. Senior managers recognise that inadequate staffing is ‘burdensome’ on existing staff, resulting in staff feeling that work is relentless (Woolnough et al, 2013; Drennan et al, 2016). Health visitors discuss how inadequate staffing reduces their ability to work in the way that they would like (Brook et al, 2019). Nurses also relate high staff turnover and a lack of staff as demotivating, negatively affecting morale (Roth et al, 2022; Mayes et al, 2023).

    Senior managers identified that career progression can be stunted when relevant training has not been completed, but a lack of funding can be a barrier to them supporting staff to attend courses (Drennan et al, 2016). Inadequate staffing further influences this issue, as managers cannot compromise patient safety by releasing staff to attend further education (Drennan et al, 2016).

    It is reported that rotation programmes for newly qualified staff and preceptorship programmes support staff development, but there is inconsistency in preceptorship provision across NHS Trusts (Drennan et al, 2016); therefore, achieving career goals can be dependent on the availability of opportunities.

    Woolnough et al (2019) reported on systemic barriers to women's career progression in the NHS. At the commencement of an education programme for career development, both the participants and those in the control group all articulated an awareness of an invisible barrier to their progression, identified as the ‘glass ceiling’ (Woolnough et al, 2019).

    Some individuals referred to a disproportionate number of male senior leaders in their organisations and some attributed their lack of career progression to their gender (Woolnough et al, 2019). Those who did not expressly acknowledge a glass ceiling were more likely to attribute female career progression with access to more influential people and their ‘faces fitting’ rather than associating progression with skill sets and capabilities (Woolnough et al, 2019).

    Participants who achieved promotions reported that once promoted, further barriers to progression and gender imbalance became evident and a recognition that female nurses' voices are often ignored (Woolnough et al, 2019). The researchers conclude that the findings highlight the gender career progression disparity within the NHS (The Health Foundation et al, 2018; Punshon et al, 2019). This finding indicates that health visitors are likely to be at a disadvantage as they are a workforce primarily made up of women.

    Discussion

    This review has identified that career progression is linked to increased affective commitment, with access to opportunities resulting in positive effects on staff wellbeing, while those lacking opportunities experience negative effects on their wellbeing. This correlates with previous studies, which have found that affective commitment buffers the adverse effects of work stressors (Begley and Czajka, 1993; Donald and Siu, 2001), strengthening staff resilience. Dominguez et al (2020) found that affective commitment increases employees' perceptions of autonomy, which positively influences wellbeing. They also found that higher levels of autonomy increased employee engagement, which is a highly motivating wellbeing outcome (Dominguez et al, 2020).

    Access to career progression opportunities is associated with increased empowerment, autonomy, motivation, self-efficacy and resilience, which are all features of psychological capital (Luthans and Broad, 2022). Improved employee wellbeing and overall performance is strongly associated with high levels of employee psychological capital (Luthans and Broad, 2022). The research analysed in this review has illustrated how employees' affective commitment and, consequently, staff retention, can be improved when individuals experience a greater sense of empowerment and autonomy. The effects of improving the psychological capital of staff are beneficial to organisations, who are more likely to achieve their goals with a more engaged workforce (Jafari et al, 2021). The inevitable effect is better outcomes for healthcare service users (Parastar et al, 2014; Guo et al 2016; Harms et al, 2017) and the benefits to individual employees' wellbeing.

    Creating an empowered workforce is closely associated with structural empowerment, which is the provision of social structures in the workplace such as access to opportunities, relevant information, support and resources, that support the achievement of individuals' work goals (Kanter, 1977).

    Research has shown that workplace empowerment strategies have a positive impact in nursing populations, increasing staff retention (Laschinger et al, 2009), employee engagement, job satisfaction and subsequently, reduces turnover intention (Boamah and Laschinger, 2015). Research also demonstrates that having structural support in place has a stronger influence over work engagement than the effects of increased psychological capital alone (Boamah and Laschinger, 2015). Therefore, organisations are more likely to improve staff retention if they provide opportunities for progression in a structured manner in addition to wellbeing packages that support staff's emotional wellbeing.

    The creation and implementation of career pathways are a positive structural support system that could improve the psychological wellbeing of employees, increase affective commitment and reduce turnover of staff. It could be argued that structured career pathways support Trusts in becoming more inclusive and ensuring equity across nursing disciplines, as staff who want to progress are more likely to achieve their goals with the right support and attribute their progression to their own development journey as opposed to luck, chance, their faces fitting or having access to influential people, as discussed by Woolnough et al (2019). The provision of career progression opportunities is strongly associated with increasing the appeal of community nursing roles and retaining existing community nurses (Martin and Hutchinson, 1997; Hemstrom et al, 2000). Researchers investigating staff retention in primary healthcare settings have concluded that career pathways are a crucial piece of the puzzle in recruitment and retention (Goodloe et al, 1996; Cutcliffe and McFeely, 2001).

    A lack of career progression opportunities is linked to difficulties in recruitment and retention of staff (Brookes et al, 2004), with Chang et al (2018) correlating a lack of advancement opportunities with reduced affective commitment, increasing turnover (Guerrero et al, 2017).

    This review has identified that nurses and health visitors perceive one of the main barriers to their career progression as a lack of career pathways and opportunities (Whittaker et al, 2013; Drennan et al, 2016; Woolnough et al, 2019; Brook et al, 2019; Kallio et al, 2022). Participants in several studies discussed options for progression as limited, a view also expressed in a recently published qualitative research paper on the perspectives of nurse retention in hospitals (Seller-Boersma et al, 2023). Health visitors reported that one of their main reasons for leaving the role was to pursue career progression opportunities elsewhere (Brook et al, 2019), which clearly communicates that health visitors are motivated by career progression.

    NHS Employers (2022) promote the use of career pathways to retain staff. A case study of an NHS emergency department that implemented a career pathway to develop support staff into nursing associates reduced staff turnover from 24% to 8% over a 3-year period (NHS Employers, 2022). A community healthcare NHS Trust that focused on retaining the existing workforce through a range of career development programmes has seen vast improvements (NHS Employers, 2023). It reports that the structured development programmes have resulted in fewer vacancies in areas they had previously struggled to recruit into, plus a significant increase in cohort numbers for allied health professional apprenticeships (NHS Employers, 2023).

    Another key finding from this review was that organisations and wider society are not perceived as valuing nurses (Zhu et al, 2021; Kallio et al, 2022; Roth et al, 2022; Mayes and Cochran, 2023), with nurses' salaries reported as a reflection of how little they are valued, perceiving their poor remuneration as discrimination against their profession as a whole (Kallio et al, 2022).

    As Woolnough et al (2019) showed, systemic barriers to female career progression highlight the detrimental impact of ‘perceived discrimination’. This is an individual's perception of being treated differently based on their gender, age, religion or disability, for example, representing a perceived injustice. Chang et al (2017) suggest this can result in a loss of affective commitment to the nursing profession and that perceived discrimination is negatively correlated with affective professional commitment.

    As the nursing profession is disproportionately female, representing 70% of the NHS workforce (NHS England, 2023b) and 99% of health visitors (Department of Health, 2012), the effects of the glass ceiling are pertinent to this review. Lack of career progression for female health professionals could lead to a reduced sense of self-efficacy that is demotivating and disempowering, leading to a reduction in affective commitment (Luthans and Broad, 2022), whether professionals are aware of this barrier or not. However, if health visitors perceive their lack of opportunities for progression as discrimination, this is also likely to negatively influence their affective commitment to their organisations and the health visitor role itself (Chang et al, 2017).

    Despite organisations having gender diversity policies, women in senior leadership positions continue to be under-represented worldwide (Ibarra et al, 2013). As recently as 2017, there was an imbalance of female representation at senior level in the NHS (Rimmer, 2017), suggesting that the obstruction to female career progression is more complex than can be sufficiently addressed by policies alone. Research shows that the presence of a subtle gender bias persisting in organisations and in society interferes with women's ability to see themselves as leaders (Ibarra et al, 2013) and may, in part, explain why a lack of opportunities continues to be an issue. Without the ability to identify with the traits of a leader that do not fit with stereotypical views of femininity (Heilman et al, 1989; Schein, 2001; Fletcher, 2004), women are less likely to pursue career progression.

    The identification of female misogyny as a phenomenon perpetuating the existence of the glass ceiling indicates deeply ingrained societal attitudes (Seabright, 2022). Reports of unsupportive colleagues and leadership throughout several of the reviewed papers were associated with negative effects on morale. This is an important consideration for female workforces, as a lack of support and affirmation can have a detrimental impact on confidence, discouraging them from aiming higher or pursuing more senior roles (Ibarra et al, 2013). This finding is a consistent theme across a number of studies, with nurses reporting how crucial a supportive culture is to their wellbeing and their ability to develop (Chang et al, 2018; Dominguez et al, 2020; Seller-Boersma et al, 2024).

    For health visitors in England there is currently no career structure once qualified. Chang et al (2018) conclude that barriers to progression need to be removed while ensuring that support is in place, as doing so increases employees' affective commitment and staff retention. It may be that a lack of opportunities could be having a strong negative influence on affective commitment because it perpetuates an overall sense that nurses and health visitors are not worth investing in as suggested by Zhu et al (2021).

    The presence of a gender bias represents an unhealthy undertone of inequality that quietly exists so that those most affected are unaware of its presence (Woolnough et al, 2019). However, they are aware that there is an unacknowledged ineffable barrier that, until educated about, they cannot necessarily name (Woolnough et al, 2019). This, in itself, undermines health professionals' sense of autonomy over their careers. Providing career pathways for health visitors could demonstrate an investment in them as individuals, respect for the role they have in supporting children and families, and promote the retention of the workforce.

    Recommendations

  • Structured career progression pathways should be considered for health visitors
  • Health visitors should be supported in their personal development by having allocated time during working hours to attend courses and/or work on projects that equip them for more autonomous working and skills required for career progression.
  • All equality, diversity and inclusion policies should include specific strategies on female career progression.
  • Conclusion

    Due to the significant shortfall in health visitor numbers in England and the links that previous research has found between career progression and staff retention, this review investigated the relationship between career progression opportunities and the retention of health visitors.

    A number of barriers to career progression were identified and all were associated with staff turnover, intention to leave and negative effects on staff wellbeing. The main barriers were a lack of structured career pathways, a lack of opportunities to progress, staff shortages, a lack of funding availability for staff training and gender inequalities.

    This review has discussed how the existing barriers to progression could be removed by implementing career pathways. As the evidence has demonstrated, supporting staff in their development has a positive impact on staff wellbeing but also on organisations as employee affective commitment is significantly improved. Further research on the retention of health visitors is required, but this review shows the positive impact career pathways could have on the retention of health visitors.

    Key Points

  • Career progression opportunities are found to support staff retention due to increasing motivation, job satisfaction, increasing autonomy and empowerment which results in increased affective commitment
  • Health professionals link career progression to a sense of being valued and recognised, which is an important influence in staff wellbeing
  • Multiple barriers to career progression exist, generating a sense of stagnation, and limiting expectations and options, resulting in reduced affective commitment and increased staff attrition
  • Career pathways are an evidence-based approach to supporting staff retention and are recommended as a tool for organisations to implement in improving the retention of health visitors
  • CPD

  • What factors would encourage you to continue health visiting?
  • What has your experience of career progression been in healthcare?
  • Have you experienced barriers to progression in your career in healthcare?
  • What are your views on career pathways in health visiting?