Recruitment and retention of health professionals across Europe: A literature review and multiple case study research
Introduction
Many European countries are faced with health workforce shortages, either current and/or forecasted. It is estimated that by 2020 there will be a shortfall of one million health workers in Europe [1], [2], [3]. These shortages are particularly critical within certain health professions or specialisations – including nursing and general practice – while almost all countries are faced with imbalances in the geographical distribution of health professionals – mostly an undersupply in rural and sparsely populated areas and oversupply in some urban areas [1], [4]. Health workforce shortages are primarily driven by demographic changes in the population, an increasing demand for healthcare, a growing number of chronically ill patients and an ageing workforce [3], [5], [6], [7]. Yet some of the shortages are also generated by austerity measures in which governments and employers are limiting recruitment, replacement and retention to meet savings targets. In view of these developments, there is a growing recognition of the need to develop effective recruitment and retention (R&R) strategies for health workers across Europe [5].
Health workforce issues have clearly moved up the agenda of European policy makers [2], [3] and various research and collaboration projects have been conducted in recent years. Examples are MoHProf Mobility of Health Professionals [8], RN4CAST [9], PROMeTHEUS Health Professional Mobility in Europe [10] and the Joint Action on Health Workforce Planning and Forecasting [11]. Nevertheless, European cooperation in the area of recruitment and retention remains underdeveloped. This is somewhat surprising, as the European Union (EU) labour market regulation has created specific incentives towards mobility of health professionals between member states and candidate countries [2], [3], [12], [13]. This may result in policies to sustain the health workforce in one country having an unintended impact on the availability of health workers in another. For example, Bulgaria and Romania have high levels of outward migration for all health workers. Although enough vacancies are available to deploy health workers within these countries, the attraction of Western and Northern European countries which suffer from domestic health workforce shortages and are able to offer higher pay and better working conditions, are decisive factors for health professionals’ leaving their country [14].
The European Commission's Action Plan for the EU health workforce, adopted in 2012, identifies staff recruitment and retention in the healthcare sector as one of the key areas for European cooperation. Stimulating exchange on innovative and effective recruitment and retention strategies is identified as one of the prioritised actions [1], yet comparative reviews on recruitment and retention in Europe are scarce. The reviews that are available have often focussed on specific types of health professionals – such as hospital-based nurses [15] – or specific problems – e.g. recruitment and retention in remote and rural areas [16], [17]. This leaves policy makers and health managers with limited intelligence to underpin the development of recruitment and retention strategies in their specific context [5], [17]. This study aims to contribute to, and deepen understanding of recruitment and retention of health workers by providing an overview of the range of measures in place across Europe and to gain further insight into their effectiveness. The main focus of the study is on R&R of physicians and nurses, as these make up the bulk of the health workforce [1], [4]. Furthermore, because of the specific EU labour market regulation and its influence on mobility and R&R of health professionals, the study scope is limited to Europe.
Up until now, it remains unclear to what extent European countries are dealing with comparable challenges in recruitment and retention, use similar interventions, what the effects of interventions are and what facilitators and barriers to successful interventions are. Moreover, there is a lack of knowledge about the specific influence that policy and organisational levels have on recruitment and retention, although the need for action at both levels has repeatedly been advocated [18], [19], [20]. The organisational context is important for understanding how to recruit and retain healthcare staff. Factors such as transformational leadership, a flat management structure and organizational structures that support professional autonomy are known to increase nurse retention [21], [22], [23]. At policy level, responses and actions taken have a huge impact on the health workforce and vary depending on whether a country is a ‘source’ or a ‘destination’ country, whether there are geographical imbalances in health worker distribution in the country, whether there is a lack of specific categories of health professionals and what the underlying problem is— e.g. not enough potential supply versus not enough financial resources to hire more staff. However, little is known about the interaction between policy and organisational levels in recruitment and retention of health workers, exemplified by a study on mental health workforce turnover [24]. Yet there are indications that this interaction can be improved. It has, for example, been concluded that the hospital/organisational level needs broader national and regional policy support in its efforts to retain existing staff and attract those who have left [3]. This study takes both policy and organisational levels into account as they have distinct, but complementary roles in the recruitment and retention of health workers.
The aim of this study was to provide an overview of the range of measures in place across Europe to improve the recruitment and retention of the health workforce and to gain further insight into the evidence base for R&R; the interaction between policy and organisational levels in driving R&R outcomes; the facilitators and barriers throughout the process; and good practices that can be identified across Europe. The following research questions were addressed:
- 1.
What are the main drivers for recruitment and retention of health professionals across Europe?
- 2.
What are the most frequently used categories of recruitment and retention interventions for health professionals?
- 3.
To what extent and how is the effectiveness of interventions to recruit and retain health professionals measured and what are the outcomes?
- 4.
What is the interaction between policy and organisational levels in the recruitment and retention interventions of health professionals?
- 5.
What facilitators and barriers can be discerned in the recruitment and retention of health professionals?
- 6.
What good practices can be discerned in the recruitment and retention of health professionals?
Section snippets
Methods
The study used a multi-method approach. It started with a review of the literature to provide an overview of recruitment and retention interventions across Europe, followed by eight case studies to gain more in-depth knowledge. Throughout the study, all identified R&R interventions were categorized according to a framework adapted from the WHO's (2010) ‘Global policy recommendations on increasing access to health workers in remote and rural areas through improved retention’ [16]. This adapted
Search and inclusion results literature review
The searches resulted in an initial set of 42,727 references of potential interest. Following an initial screening based on title and abstract, and removal of unobtainable references and duplicates, 996 references were selected for full text screening. After application of the inclusion criteria, 64 publications were selected for data-extraction and analysis. Fig. 1 shows the flow diagram of the inclusion process.
Characteristics of the 64 publications included in the literature review
Of the 64 publications, covering 27 EU and EEA/EFTA countries, 37 were grey
Discussion
Our study showed that most R&R interventions in Europe are triggered by similar pressures and motivations, such as shortages of a specific category of health workers. Most R&R interventions also tend to take the same shape; professional and personal support and educational interventions are most commonly used. In view of these similarities and the European Commission's Action Plan for the EU health workforce, adopted in 2012, which identifies R&R in the healthcare sector as one of the key areas
Conclusion
In view of the current lack of evidence base on recruitment and retention, it would be beneficial for European countries and organisations to learn from each other's good practices and take into account the factors that facilitate the translation of R&R interventions from one context to another. This calls for high context-sensitivity given that targets, resources and governance arrangements of different countries come into play [2]. Simultaneously, investments should be made in multi-method
Conflict of interest statement
None of the authors has any potential conflict of interest related to this manuscript.
Acknowledgments
This project was funded by the European Union through the EU Health Programme (2008–2013) in the frame of a specific contract with the Consumers, Health, Agriculture and Food Executive Agency (Chafea) acting on behalf of the European Commission (2013 62 03—EAHC/2013/Health/08). The funding source had no involvement in the conduct of the study, but approved of the decision to submit this article for publication.
The authors wish to thank Judith van den Broek PhD, Claudia Leone MSc, Paula Oliveira
References (96)
- et al.
Bringing a European perspective to the health human resources debate: a scoping study
Health Policy
(2013) - et al.
Mobility of health professionals pre and post 2004 and 2007 EU enlargements: evidence from the EU project PROMeTHEUS
Health Policy
(2012) - et al.
Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature
International Journal of Nursing Studies
(2007) - et al.
Effective strategies for nurse retention in acute hospitals: a mixed method study
International Journal of Nursing Studies
(2013) - et al.
Retaining nurses in their employing hospitals and in the profession: effects of job preference, unpaid overtime, importance of earnings and stress
Health Policy
(2006) The clinical role of nurse lecturers: past, present, and future
Nurse Education Today
(2007)- et al.
Did Project 2000 nurse training change recruitment patterns or career expectations?
Nurse Education Today
(2000) - et al.
Flexible working and the contribution of nurses in mid-life to the workforce: a qualitative study
International Journal of Nursing Studies
(2010) Commission Staff Working Document on an Action Plan for the EU Health Workforce
Report No.: Contract No.: SWD(2012) 93 final
(2012)- et al.
Health professional mobility and health systems in Europe: an introduction
Health Professional Mobility and Health Systems
(2011)
Recruitment and retention of the health workforce in Europe
Policies to sustain the nursing workforce: an international perspective
International Nursing Review
Supporting health systems in Europe: added value of EU actions?
Health Economics, Policy and Law
From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management
Human Resources for Health
MoHProf mobility of health professionals
RN4CAST nurse forecasting in Europe
PROMeTHEUS health professional mobility in Europe
Joint action health workforce planning and forecasting
EU level collaboration on forecasting health workforce needs, workforce planning and health workforce trends—a feasibility study
Scaling the mobility of health workers in an enlarged Europe: an open political-economy perspective
European Urban and Regional Studies
Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations
Systematic review of effective retention incentives for health workers in rural and remote areas: towards evidence-based policy
Australian Journal of Rural Health
Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States
British Medical Journal
Enhancing working conditions
Innovative solutions to skill shortages in health: research and practice
The relationship between effective nurse managers and nursing retention
Journal of Nursing Administration
The role of staff turnover in the implementation of evidence-based practices in mental health care
Psychiatric Services
Qualitative methods for health research
Creating good workplaces: retention strategies in health-care organizations
Institutional work to maintain professional power: recreating the model of medical professionalism
Organization Studies
Evaluative criteria for qualitative research in health care: controversies and recommendations
The Annals of Family Medicine
Case study research
Improving first-destination recruitment: nursing students’ perceptions of three initiatives in London, England
Journal of Nursing Management
Recruitment and retention of health care professionals in the Nordic Countries: a cross-national analysis
Early community-based family practice elective positively influences medical students’ career considerations—a pre-post-comparison
BMC Family Practice
The developing role of Transition to Practice programs for newly graduated mental health nurses
International Journal of Nursing Practice
Post-graduate training at the ends of the Earth—a way to retain physicians
Rural and Remote Health Journal
A review of nursing workforce policies in five European countries: Denmark, Finland, Ireland, Portugal and United Kingdom*/England
Journal of Nursing Management
Evaluation of return to practice: the views of nurse returnees from three NHS hospital trusts
Journal of Nursing Management
Health care systems in transition: Czech Republic
The health care workforce in Europe: learning from experience
Investing in Europe's health workforce of tomorrow: scope for innovation and collaboration. Summary report of the three Policy Dialogues
Whole-system evaluation research of a scheme to support inner city recruitment and retention of GPs
Family Practice
Health system review
Profile of English salaried GPs: labour mobility and practice performance
British Journal of General Practice
Greece: health system review
Health Systems in Transition
Belgium: health system review
Health Systems in Transition
The new GMS contract: impact and implications for managing the changes
Health Services Management Research
Cited by (93)
‘They don't actually join the dots’: An exploration of organizational change in Irish opiate community treatment services
2022, Journal of Substance Abuse TreatmentCitation Excerpt :Recruitment and retention of staff was discussed as a factor which simultaneously inhibited the implementation of change and organizational ability to meet the needs of service users. In the context that providing OST services have significant economic benefits for wider society, the pay and conditions and career opportunities awarded to staff are likely to impact on this, and are worthy of further attention (Gossop, 2015; Kroezen et al., 2015). Maintaining good relationships with service users in order to obtain information about changing trends and emerging difficulties, is also likely to be of paramount importance as service user need was consistently identified as a driver of change.
Medically underserved areas: are primary care teams efficient at attracting and retaining general practitioners?
2021, Social Science and Medicine
- 1
Tel.: +351 2 1365 2600.
- 2
Tel.: +31 20 568 8658.
- 3
Tel.: +31 20 568 8256.
- 4
Tel.: +44 131 474 0000.
- 5
Tel.: +44 20 7848 3029.
- 6
Tel.: +44 20 7836 5454.
- 7
Tel.: +32 2 502 65 25.
- 8
Tel.: +32 16 37 33 49.