Elsevier

Health Policy

Volume 119, Issue 12, December 2015, Pages 1517-1528
Health Policy

Recruitment and retention of health professionals across Europe: A literature review and multiple case study research

https://doi.org/10.1016/j.healthpol.2015.08.003Get rights and content

Highlights

  • There is little evidence about the effectiveness of recruitment and retention interventions.

  • Single recruitment and retention interventions have little impact; packages are more effective.

  • Successfulness of recruitment and retention interventions is dependent on their context-sensitivity.

  • Good practices in R&R include having political and executive commitment.

Abstract

Many European countries are faced with health workforce shortages and the need to develop effective recruitment and retention (R&R) strategies. Yet comparative studies on R&R in Europe are scarce. This paper provides an overview of the measures in place to improve the R&R of health professionals across Europe and offers 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 these process; and good practices in the R&R of health professionals across Europe. The study adopted a multi-method approach combining an extensive literature review and multiple-case study research. 64 publications were included in the review and 34 R&R interventions from 20 European countries were included in the multiple-case study. We found a consistent lack of evidence about the effectiveness of R&R interventions. Most interventions are not explicitly part of a coherent package of measures but they tend to involve multiple actors from policy and organisational levels, sometimes in complex configurations. A list of good practices for R&R interventions was identified, including context-sensitivity when implementing and transferring interventions to different organisations and countries. While single R&R interventions on their own have little impact, bundles of interventions are more effective. Interventions backed by political and executive commitment benefit from a strong support base and involvement of relevant stakeholders.

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

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