Realist evaluation of factors affecting the retention of the mental health workforce: building a realist programme theory

Objective: The shortage of mental healthcare workforce is a global problem. Mental health services have higher staff turnover and more vacancies than the health sector average. In this study, we developed, tested and refined an initial programme theory (IPT) to offer insight into mechanisms that affect staff retention in UK mental health provider organisations.

Design: A realist evaluation to identify the contexts and mechanisms that impacted on workforce retention. We developed an IPT through a realist review and stakeholder engagement.

Setting: We then tested the IPT through a realist evaluation in six case studies in selected National Health Service (NHS) mental health Trusts in England. Sites were selected to give variation in retention rates; quality ratings were awarded by the national healthcare regulator, staff satisfaction levels and geography.

Participants: Realist interviews (199) were conducted with senior executives and registered mental health clinicians. Data were analysed using an iterative realist approach to analyse the links between the context, mechanism and outcomes and test and revise initial programme theories. The study has been reported in line with Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) II guidelines.

Results: Data allowed us to refine the IPT. Workplace contexts influenced the key mechanisms of ‘perceived quality of care and the ability to make a difference’, ‘psychological safety’, ‘feeling valued’ and ‘feeling connected’, all of which influenced intention to leave.

Conclusions: The final programme theory highlighting key contexts and mechanisms for improving retention among mental health staff in the NHS is presented. Organisational culture underlies all other contexts and mechanisms.