Authors' objectives: Social care staff shortages are having a detrimental impact across the health and care system. There are reports of care homes closing, stopping nursing services and not admitting new residents because of challenges with staff shortages. Social care staff shortages are having a detrimental impact across the health and social care system. There are reports of care homes closing, stopping nursing services, and there are care homes not admitting new residents because of challenges with staff shortages. Research aim: to develop an explanatory framework (underpinned by programme theories) of effective strategies to attract, recruit and retain registered nurses (RNs) and care workers working in care homes.

Authors' results and conclusions: During step 1, strategies used to attract, recruit, and retain registered nurses and care workers were identified and initial programme theories developed (n = 22). Ten strategies and initial programme theories were prioritised for testing/refining and were focused on recruitment and retention: staff recognition, flexible working, career development, salary package, early investment, induction, continuous feedback, caring community, effective interviewing and listening to all staff. From the focused literature searches, 153 papers were included and data from these were used to test and refine the prioritised strategies and initial programme theories, and throughout the process collated into five final theories: effective interviewing, career development, reward and recognition, promoting work–life balance and caring conversations. These strategies do not operate independently; they interact and work together. Effective interviewing sets accurate expectations, and loyalty starts to develop through setting an accurate ‘psychological contract’ which is fulfilled over time. Opportunities for career development, rewarding and recognising staff, providing flexible working options and supporting staff with caring conversations help staff to feel listened to, respected and valued, which in turn, develops job satisfaction. Supportive leaders and a sense of inclusion and fairness are needed for these strategies to work. These strategies provide staff with positive experiences, and these are reciprocated through employee commitment and loyalty. Supporting staff through providing caring conversations and opportunities for career development also help staff feel empowered. This is the first realist synthesis in this field. The findings provide practical strategies for improving staff recruitment and retention. During step 1, strategies used to attract, recruit, and retain RNs and care workers in care homes were identified and IPTs developed for each (n = 22). Ten IPTs were prioritised for testing and refinement, these focused on recruitment and retention: staff recognition, flexible working, career development, salary package, early investment, induction, continuous feedback, caring community, effective interviewing and listening to all staff. From the focused literature searches, 153 records were rated as very relevant and used to test and refine the prioritised IPTs. Throughout the testing and refining process, the theories were collated and combined into five: effective interviewing, career development, reward and recognition, promoting work–life balance, and caring conversations. These strategies and programme theories are summarised below. This is the first realist synthesis of the literature in this field. We have identified real world practical strategies used to recruit and retain RNs and care workers in care homes: effective interviewing, career development, reward and recognition, promoting work–life balance and caring conversations. We have used existing evidence (and stakeholder input) to explain how and why these strategies work, the conditions needed, the outcomes to be expected, and the costs involved. Where evidence was available, we also describe the staff characteristics for whom these strategies are important. The care home (and the wider social care) sector has been a difficult policy area for many governments over the past 30 years, and for this reason there is a history of being overlooked by policy-makers. It is imperative that evidence-based solutions developed to address the challenges faced by the sector are shared widely with central government and policy decision-makers. The strategies put forward are underpinned by a large, diverse and international evidence base. Providing solutions based on evidence is important for future policy-making, commissioning, funding and impact. Understanding how to attract new staff to the social care workforce remains an important research gap.

Authors' methods: A realist synthesis approach was used. In step 1, strategies were identified and initial programme theories developed using data from stakeholder consultations (n = 10), theory gleaning interviews with registered nurses and care workers (n = 13), and evidence retrieved from scoping literature searches (n = 50). Strategies (and initial programme theories) prioritised by sector stakeholders focused on staff recruitment and retention, and were taken forward for testing/refinement. Step 2 involved searching academic databases and social care websites for evidence. Step 3 involved screening and selecting records relevant to the prioritised initial programme theories. Relevant data were extracted and analysed to identify context–mechanism–outcome configurations. To assess rigour, the appropriateness of research methods, and the plausibility/transparency of grey literature were assessed. Step 4 involved testing and refining the programme theories, with programme theories sense checked/refined by sector stakeholders. Existing and established theories were used to help further explain the programme theories and develop an overarching explanatory framework. Stakeholder consultations did not include the views of staff who had left care work. A realist synthesis approach was used to identify strategies used to attract, recruit, and retain staff, and develop programme theories explaining how and why the strategies work, for whom, the conditions needed, outcomes to be expected, and the costs involved. Four steps were followed: During the first step, IPTs were developed using data gathered from: theory gleaning interviews with RNs (n = 5) and care workers (n = 8), exploring why staff were attracted to care home work, experiences of recruitment and induction, and the reasons why he/she intends to stay or leave. consultation meetings with sector stakeholders (n = 10). Stakeholders commented on the scope of the review, outcomes underpinning attracting, recruiting, and retaining staff, the conditions needed, contextual factors and the staff groups to consider. scoping literature search on academic databases and Google (Google Inc., Mountain View, CA, USA) searches retrieved 1033 records of which 50 records contained relevant data. The data were used to identify practical strategies used to attract, recruit, and retain staff (n = 22), and IPTs were developed for each. The 22 IPTs were reviewed by the study team and after discussing the clarity/logic and the relevance/importance, the IPTs were reduced to 15 IPTs. The 15 IPTs were reviewed by sector stakeholders (n = 34) and 10 IPTs prioritised for further testing and refining (steps 2–4). The prioritised IPTs were focused on staff recruitment and retention (and not on attracting staff) – these were taken forward for further testing and developing. During step 2, academic databases and social care websites were searched for evidence. Step 3 involved screening/selecting articles from the records retrieved during step 2, and extracting and analysing data from included articles. When screening records, the rigour and relevance of articles were rated. To assess rigour, the appropriateness of methods used in research, and the plausibility and transparency of grey literature were assessed. When assessing relevance, articles were rated on a scale, and only very relevant articles were included (n = 153). Very relevant articles were those containing content relevant to one or more IPT(s) and with content describing causal linkages between two or more components of IPTs. Data analysis involved extracting data with causal linkages and beginning analysis with assigning codes using both inductive and deductive reasoning. During step 4 the data were brought together to test and refine the IPTs, using the evidence to shape, refine and provide a narrative synthesis around each strategy – describing what the strategy involves, why and how it works, for whom, the conditions needed, the expected outcomes, and the associated costs. Programme theory drafts were sense checked and refined by sector stakeholders, using both online and in person meetings in care homes. The final programme theories were examined side by side to examine if and how the individual strategies/programme theories interacted. The links between strategies (and accompanying programme theories) were illustrated using an explanatory framework. Existing and established human resource (HR) and employee management theories were used to further explain the explanatory framework.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR131016

Year Published: 2026

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/GJRD0408

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/GJRD0408

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk