A service improvement project of a legacy nurse programme to improve the retention of late career nurses

Background A Nottingham Legacy Nurse Programme was developed in response to the reducing supply of new nursing registrants and an ageing workforce. The programme comprised components of focussed mentorship, knowledge transition, support and development of new learners in practice. Aims The work-based development programme aimed to improve the retention and experience of late career registered nurses. Methods The programme was informed by the evidence base and co-produced with late career registered nurses (aged 55 years or over, approaching retirement). A small pilot programme (n = 6) was evaluated through a mixed-methods approach. Refinements and recommendations were proposed in response to findings of a scoping search of the literature, feedback from participants and stakeholder groups across the NHS Midlands and East regions (n = 238). Results A Legacy Nurse programme has potential to address nurses’ individual career development needs, valuing and retaining them in the workforce, enabling them to share professional knowledge and skills within clinical teams and offers a cost-effective solution to improving retention of late career nurses. Conclusions Addressing the needs of late career registered nurses is required to improve retention, job satisfaction, quality-of-care provision and facilitate knowledge transfer. The programme requires evaluation in other care settings and should be considered as part of an integrated approach to nurse retention, inclusive talent management and workforce planning, alongside financial and careers advice.


Introduction
Improving retention of the workforce is a critical priority facing health and social care globally, with concerns about an ageing nursing profession reported by many international nursing organisations. The International Centre on Nurse Migration, (Buchan et al., 2018) reported organisational factors which impact on nurse satisfaction and retention, including: the working environment, working relationships; financial and non-financial incentives; flexible working; career and educational opportunities; responsive management, effective supervision and focussed mentoring; and job opportunities in different organisations, sectors, regions and countries. The World Health Organisation, International Council of Nurses and Burdett Trust for Nursing in the UK, launched the 'Nursing Now' campaign (2019), which highlights that, globally, nine million more nurses and midwives are needed by 2030 and action is needed to improve nurses' working conditions, training and leadership skills (Nursing Now https://www.nursingnow.org/).
In England, nursing shortages have been reported as the most urgent workforce priority facing the NHS, with 40,000 reported vacancies in substantive nursing posts (NHS England, 2019b). The UK-wide Royal College of Nursing (RCN) employment survey 2019 identified that nearly a quarter of nurses and midwives were looking for a job outside the NHS (2019). Almost a third of qualified nursing, midwifery and health visiting staff in the UK are over 50 years old, with one in three nurses due to retire in the next 10 years (Nursing and Midwifery Council, 2017;Jones et al., 2015;King's Fund, 2018). The Royal College of Midwives (RCM) (2017) warns that one in three registered midwives in the UK are now over 50 years of age (NHS Digital, 2019). In a survey of 1,626 nurses who left the professional register in the UK between November 2018 and June 2019, retirement (52.7%) was identified as the top reason (Nursing and Midwifery Council, 2020). The average age of leaving the professional register has reduced steadily from an average of 55 years of age in 2013 to 51 years of age in 2017 (Nursing and Midwifery Council, 2017).
The nursing workforce crisis has only been further exacerbated as a result of the Covid-19 pandemic, with ongoing inequalities, increasing workforce pressures and challenging working conditions (Borneo et al., 2020). Following the first phase of the response to the Covid-19 pandemic, the importance of a culture of compassionate and inclusive leadership which prioritises staff retention, health and wellbeing has been identified as essential to enable staff to carry out their work caring for others  and this is central in the NHS People Plan for 2020-21 (NHS England, 2020). There is an even greater emphasis and focus required on the retention of a workforce experiencing unprecedented pressures. West and Dawson (2012) describe three core 'ABC' human work needs to ensure nursing and midwifery wellbeing and motivation at work, and to minimise workplace stress: autonomy, belonging and contribution.
Managing a multi-generational team requires managers and organisations to adopt a more flexible approach to work organisation, task management and duty rotas (NHS Employers, 2017). Requests to work flexibly, part-time and in job-share are common among the older workforce (Royal College of Nursing, 2016). Working flexibly may enable older nurses and midwives to work to the top of their potential, with longer recovery periods and more time to manage other family or carer responsibilities. The NHS Working Longer Review (University of Bath and The NHS Staff Council, 2014) identified that organisations can enable nurses to retain employment by providing early intervention services (occupational health services, physiotherapy or counselling), discussing and planning with staff themselves to identify the measures they need to help them to work in clinical settings. Helping staff to make plans for their future career and retirement at an early stage will facilitate retaining older workers and enable them to work effectively (NHS England, 2019b;NHS Employers, 2017).
The House of Commons Health Committee Report (2018) identified that a reduction in the availability of post-registration funding for training and development was a major issue contributing to nurses leaving the profession. In addition, newly qualified staff have reported the pressures of challenging working environments, when experienced staff do not have time to support them adequately. Lack of recognition, esteem and low rewards have been identified across Europe as the main reasons for nurses of all ages leaving the profession (Li and Jones, 2013). The Working Longer Review (University of Bath and The NHS Staff Council, 2014) identified that older workers in particular often feel under-valued and not respected by managers and colleagues. The 'Mind the Gap' Report (Jones et al., 2015) highlighted that appreciating each generation for the strengths they bring to the team facilitates a higher level of team performance. The RCN (2016) recommend the introduction of a learning strategy, providing midlife development reviews for career planning with psychological and financial planning. Interventions are required to develop the skills and knowledge of managers in their role in supporting an older workforce.

Regional context
As one of a number of nurse retention initiatives underway across the East Midlands region of England, this pilot programme aimed to develop a greater understanding of the needs of late career nurses and implement innovative supporting strategies to help organisations retain experienced staff. The East Midlands region is a diverse area covering six counties with 15 NHS trusts covering 12% of the total area of England with a population of 4.8 million. The area hosts significant conurbations such as Nottingham and Leicester with 29.5% of people living in rural areas. In relation to other regions of England, the East Midlands has lower levels of deprivation although it was estimated that 18.5% of the population still lived in areas classified as being in the most deprived quintile in England (2016 data). The area has an ageing population with life expectancy at birth for males and females significantly lower than England as a whole (Public Health England, 2018).

The Nottingham legacy nurse programme (NLNP) pilot
The programme was developed and led by the Institute of Care Excellence at Nottingham University Hospitals NHS Trust, on behalf of the local integrated health and social care system's professional nursing and midwifery cabinet (a group of senior nurse and midwife leaders representing organisations and stakeholders from within the local care system). It was identified that retaining the professional knowledge and skills of experienced nurses was an essential local workforce priority. Nationally within the NHS, workforce planning has traditionally been focussed on supply and pipeline to increase nursing student numbers, rather than investigating and evaluating how experienced nursing knowledge is valued and retained. Retention of the workforce is critical due to global nursing shortages, reductions in supply of new nurses coming into the profession and an increasing number of learners within the practice environment. In the NHS, this includes clinical apprenticeships, new roles and a strategic intention to retain and expand student numbers and placement capacity (Health Education England, 2018). In addition, registered nurses who work in the NHS on the 1995 NHS pension scheme are eligible to retire at 55 years old. Within an increasingly stressful workplace and as a result of the pandemic there is a risk that more will choose to leave (King's Fund, 2020).
The programme of work was funded by Health Education England (East Midlands) through the region's Nursing Supply and Demand Programme Board. This regional Board of Nurse Directors was established in 2016 to advance work on nursing workforce supply and retention across the region. An independent evaluation was undertaken as part of an Economic and Social Research Council Impact Leaders award. The programme was inspired by the Legacy Mentor project conducted by Clauson et al. (2011). The title of Legacy Nurse resonated with the aims of the programme, facilitating a way for registered nurses to develop and share their wealth of expertise with future nursing generations. The programme objectives were to • Evaluate the potential benefits of an innovative mentorship model. • Identify ways to facilitate the translation of nurses' expertise.
• Explore ways to improve retention of the late career nursing workforce.
• Explore how the programme mechanisms can impact the practice learning environment. This paper presents the stages of Nottingham Legacy Nurse Programme (NLNP) development, pilot testing, implementation and phase two wider stakeholder engagement and evaluation.

Methodology
The service development followed four stages outlined in the RE-AIM framework (Glasgow et al., 2019) to help plan the NLNP and consider the programme sustainability, adoption and implementation: Reach, Effectiveness, Adoption and Implementation. The programme objectives were addressed by: 1. completing a pilot programme 2. conducting a scoping review of the literature 3. concept mapping of a NLNP 4. developing recommendations for the next stage of the programme including wider stakeholder engagement and recommendations for implementation.
The pilot programme, scoping study and stakeholder feedback stages of the programme were conducted concurrently with quantitative and qualitative data collated and synthesised to produce overall findings and recommendations for the next stage of the programme (Creswell et al., 2004).

The pilot programme
The Nottingham Legacy Nurse Pilot Programme ran from December 2017-June 2018. Six nurses who submitted expressions of interest and had the support of their nursing managers were recruited. The Legacy Nurses were employed by three different organisations including NHS and social care providers in the region. Legacy Nurses worked in different settings, including acute and surgical care, healthcare of the older person, community nursing, school nursing and outpatient clinics.
The initial programme was based on the Legacy Mentor project conducted by Clauson et al. (2011) and consisted of two introductory days, one day per week in clinical practice to complete project work, one workshop per month and individual coaching as required with the programme facilitator. A practice development nurse, skilled in coaching techniques facilitated the programme. The Legacy Nurses had individual meetings with the facilitator to discuss and co-produce their individual 'needs led' development plan and project objectives.

Work based educational improvement projects
Legacy Nurses were asked to consider their professional knowledge and expertise to develop their own improvement projects focussed on the needs of their clinical area. This aimed to recognise and value the wealth of participants' professional nursing experience and utilise the opportunity for knowledge transition to other members of their team, including new starters and other learners. Group workshops enabled Legacy Nurses to explore project ideas and receive peer support and advice. The projects included: • Acute care and older people: an intervention focusing on staff education and raising awareness to improve bowel care assessment, management and documentation. The project also aimed to improve referral processes to specialist teams. The Legacy Nurse developed an education resource for the clinical area. The project identified savings through more efficient and targeted use of clinical supplies. • Community nursing: the project initially scoped the emerging priorities for staff retention. To support retention, an intervention was developed to support new staff which included a contacts pocket book, induction documentation package, key policies and skills development, support and training from experienced staff in complex clinical tasks, information databases and use of specialist equipment. • Acute surgical care: the project reviewed the needs of the ageing clinical nursing workforce and retirement support and evaluated the impact on retaining nursing staff and nurses returning to practice. • First responder in community care: the project provided preceptorship to new community lone working nurses. The project reduced the time required for new nurses to achieve competency in their role.

Results: pilot programme evaluation
The NLNP was evaluated using a longitudinal mixed-method approach which included pre-and post-programme self-report skills assessment and qualitative interviews conducted pre-and postprogramme. The interviews were transcribed, transcription checked against recordings and then analysed thematically. This involved a process of coding for meaning and content, and then building themes by linking groups of codes together. This was done by one researcher (ST) and the initial analysis checked and agreed at a meeting of the project team.
The study sample included all nurses who participated in the pilot programme (December 2017-June 2018). Five of the six participants completed the programme. One participant left the programme due to new employment. Participants reported a 28% improvement in their skills assessment (networking, project planning, knowledge of implementation process, managing change and communication skills). Thematic analysis in the interview data revealed the following themes: wealth of experience, energised, community of practice and protected time

Wealth of experience
Nurses who participated in the NLNP programme had developed specialist skills and experience in a variety of clinical settings. Before starting the programme, they were keen to pass on their skills and identify ways to support this. Initially Legacy Nurses under-valued their expertise, but the programme enabled them to reflect and be aware of the wealth of their professional knowledge. The programme provided time for the Legacy Nurses to mentor students and newly qualified staff, and some had used their newly developed coaching skills to support existing staff members in their clinical areas.

Energised
The Legacy Nurses described feeling energised by the programme. They had learnt new skills which they were able to apply in practice and as a result said they felt more confident. The Legacy Nurses enjoyed learning new things and found the improvements they made in practice through their individual projects very rewarding and many planned to continue developing their projects after the end of the programme. The programme was seen as a way of addressing a lack of a formal career path for experienced clinical nurses.

Community of practice
Having the time, space and support to complete the programme was described by participants as very important to the success of the programme. Group workshops away from busy clinical areas facilitated the cohesion of the group and expert facilitation provided guidance and support. All of the Legacy Nurses valued the peer support components of the programme and planned to continue meeting as a group.

Protected time
Initially, the Legacy Nurses encountered difficulty in safeguarding time to complete the programme. The facilitator offered support by communicating the programme objectives with clinical managers, although some clinical areas still struggled to release staff during busy periods.

Methods
To map the existing evidence reporting the views and experiences of late career nurses a scoping study (Arksey and O'Malley, 2005) was completed in April 2018. The aim of the review was to identify the existing literature about the retention and recruitment of late career nurses. The PCC framework (Population, Concept and Context) (Aromataris and Munn, 2020) was developed to define the scope of inquiry and inform the initial eligibility criteria for inclusion (Levac et al., 2010).
• Population: Registered nurses, healthcare managers and commissioners.
• Concept: Retention and recruitment of late career nursing staff. Nurses approaching retirement or already retired. • Context: Health and social care organisations in countries with similar structures of nursing care to the UK.
A literature search was undertaken using MEDLINE, CINHAL and The Joanna Briggs Library databases from the January 2000 to April 2018. The search included all primary research studies, policy and systematic reviews published in the English Language. The scoping search was restricted to three key databases and did not include a grey literature search due to the practicalities of time and resources. Data were extracted using a pre-designed data extraction form, designed to address the scoping review objectives: (1) To identify existing interventions to support late career nurses and (2) To identify the views and experiences of late career nurses. Data included publication year and country where the study was performed: the study design, aims, characteristics of participants and setting, intervention or phenomena, research method, findings and authors' conclusions. A table of the included studies was presented followed by a narrative description of the literature. A thematic analysis was conducted, data were categorised into initial themes. Engagement events were held with key stakeholders including participants in the pilot programme, the legacy pilot lead nurse, the nursing workforce development lead and a health services management researcher. Initial themes were presented and discussed with the stakeholders to reach consensus on the final themes and inform the reporting of the findings (Arksey and O'Malley, 2005).

Findings
The search identified 1,970 papers which were screened by a single reviewer on the information provided in the title and abstract. Papers which did not meet the inclusion criteria were excluded (n = 1,926). Forty-four papers were retrieved, and full text assessed by two reviewers, 15 papers were excluded (did not meet inclusion criteria), and 29 papers were included. There were 24 primary research studies (Table 1).
The findings reported in the included studies were reported narratively. This process was completed separately for the qualitative and quantitative studies. Data from qualitative and quantitative studies were then synthesised into key themes. Two overarching themes identified were as follows: 1. What late career nurses need to help them make choices about continuing to work and 2. What late career nurses need to help them continue working Children's nurses (44 years and older) and administrative personnel Survey + n = 10 interviews Nurses stated that they face physical and mental challenges that need to be addressed for them to continue working. The primary concern is the ability to continue to do the job for as long as possible. Some administrators reported mixed messages: longevity is appreciated but the organisation has not developed new strategies to retain older nurses. Administrators believe that the retention of older nurses must become a core purpose, part of the overall strategic plan, for change to occur. as well as interaction between nurses and patients. Patient-care centredness seems to be an important characteristic of practice for ageing hospital nurses providing wellbeing at work. Nursing managers and leaders need to take these factors into account in their work force and when managing ageing nurses with the aim of promoting their wellbeing at work and keeping experienced and highly skilled nurses on the job Literature, policy and structured reviews Graham and Duffield (2010) Literature review: To examine the impact of ageing on individuals, the ageing nursing workforce and the implications for government policy given its status Not reported Not reported Shift workers over 40 years are at risk of fatigue and decreasing performance in the workplace, which has a negative impact on patient care. Older workers who feel they have been discriminated against are more likely to retire early, feel trapped in a workplace and reluctant to find a new workplace. There is a need for research into job redesign to address the issues of heavy workload and stress for older nurses. Older nurses could undertake specific roles focusing on aspects of work such as admission and discharge processes. Investment in improvements to the workplace and equipment to prevent physical injury is recommended. A participatory style of management would address the needs of older nurses for recognition of and respect for their expertise through consultation, continual sharing of knowledge and, allowing nurses to propose workplace solutions, prioritise actions and participate in applying them. Older nurses have not been asked their retirement intentions or canvassed for strategies that would encourage them to extend their working life. The attitudes of senior health service managers are unknown (continued) What late career nurses need to help them make choices about continuing to work Information. Some nurses reported a lack of knowledge about the impact on their pensions if they continued working and needed individualised financial information to help them make decisions about how and when to retire (Andrews et al., 2005;Blakeley and Ribeiro, 2008;Storey et al., 2009;Rea, 2003).

Value and recognition
Feeling under-valued in their current role was reported as a reason for deciding to retire from nursing. Conversely when nurses perceived that their skills and experience were valued by employers, they felt more positive about continuing to work (Blakeley and Ribeiro, 2008;Clendon and Walker, 2016;Jeffs et al., 2014;Ryan et al., 2017;Storey et al., 2009;Uthaman et al., 2016). Formal feedback on job performance was important to nurses. This feedback helped them make decisions about whether to retire or continue working (Jeffs et al., 2014;Palumbo et al., 2009).

Training and opportunities
Older nurses wanted more support with the introduction of new technology (Valencia and Raingruber, 2010). Nurses reported feeling burdened by the need to keep up-to-date with professional training and to undertake academic education (Blakeley and Ribeiro, 2008;Clendon and Walker, 2016). However, some nurses would welcome the opportunity to undertake professional development, complete training to enable them to work in different settings as they reported that they have limited options for the work they were able to undertake (Andrews et al., 2005;Clendon and Walker, 2016;Uthaman et al., 2016).
What late career nurses need to help them continue working

Flexible working patterns
Some nurses reported that they chose to retire at the same time as their partners, other reasons included wanting to spend time with their families or to undertake family caring responsibilities (Durosaiye et al., 2016;Andrews et al., 2005;Uthaman et al., 2016;Rea, 2003). Shift work and working long hours were reported to negatively impact on family roles and social functioning (Durosaiye et al., 2016;Graham et al., 2014;Letvak, 2003a;Uthaman et al., 2016). The availability of flexible work patterns which accommodated nurses' caring responsibilities was an incentive to remain in employment (Utriainen et al., 2015). Although shift work has been reported as preferable for some older nurses, many nurses wanted to be able to choose the number of hours and days they worked (Andrews et al., 2005;Clendon and Walker, 2013b). Many nurses reported they felt more fatigued from working night shifts as they got older and had chosen to reduce their hours (Andrews et al., 2005;Blakeley and Ribeiro, 2008;Dziadekwich et al., 2012;Graham et al., 2014;Letvak, 2003b;Spiva et al., 2011;Uthaman et al., 2016).

Financial incentives
Nurses reported that financial security was a reason for deciding to retire. Conversely financial incentives also influenced nurses' decision to remain in work (Blakeley and Ribeiro, 2008;Duffield et al., 2015;Clendon and Walker, 2016;Letvak, 2003b;Uthaman et al., 2016).

Supportive environments
Social/peer support: nurses in the included studies reported enjoying patient contact and the camaraderie and support from colleagues (Liebermann et al., 2015;Uthaman et al., 2016). However, nurses also reported feeling guilty about their decreased ability to cope with heavy workloads, as they did not want to let their colleagues down (Clendon and Walker, 2016). Generational conflicts and staff shortages were also reported as barriers to continuing employment into nurses' late careers (Letvak, 2003a(Letvak, , 2003b. Physical support: older nurses wanted the option to work in areas which had lighter workloads and a less stressful environment. Nurses expressed fears about cognitive ability and their physical fitness. Studies suggested that the physical and cognitive demands of the job could be improved by having ergonomically designed workplaces including availability of lifting aids, ergonomic computer workstations and softer floors, reducing the distance nurses need to walk to access equipment (Stichler, 2013;Uthaman et al., 2016).

Concept mapping and refining the programme design
The conceptual framework for the NLNP was informed by the feedback from participants of the pilot programme and the scoping review. Initial theories and concepts were identified which were then further tested through wider engagement with stakeholder groups. Potentially beneficial mechanisms of change were identified (Table 2) with additional consideration of how the NLNP could maintain process fidelity, whilst providing flexibility to enable adaption to different contexts and settings (Novick et al., 2013). The format of the programme was outlined to define facilitator and participant characteristics and the programme design included key components. These were discussion groups, workshops, presentations, individual coaching support and methods of evaluation (Table 3). Participant feedback suggested that the programme runs for a minimum of 6 months with at least one day per week focussed on individual project work. Provision of long-term projects has been suggested to improve the benefit of late career nursing initiatives, alongside an opportunity to select or design projects of interest to participants (Doran et al., 2015).

Wider stakeholder engagement and recommendations for implementation
Consultations with stakeholder groups provided their views and feedback on the NLNP (Figure 1). Stakeholders were identified from across the NHS Midlands and East regions via social media platforms and email networks. Feedback from an online questionnaire was obtained from nursing and midwifery leaders and managers, healthcare public bodies, clinical nurses and midwives, clinical educators, practice development teams and higher education institutions (n = 238). The stakeholder groups were asked for their views about the needs of the late career workforce, their thoughts and interest in relation to the NLNP, ideas for potential projects and ways to engage the late career workforce.
Clinical nurses and midwives (n = 190) reported they wanted opportunity to access training and development opportunities as their careers progressed; however, older nurses and midwives sometimes felt overlooked. Flexible working contracts were defined in various ways: retire and return, shorter shifts, reduced working hours, part-time work, reduced responsibility, no requirement for night duty, fixed duty rotas and breaks between working days. However, many respondents reported similar benefits of flexible contracts which were said to help cope with the physical and Table 2. Mechanisms of change underpinning the Nottingham Legacy Nurse Programme.
Community of practice feeling valued and supported Promotes an ethos of learning and practice-based knowledge development through active engagement within a Community of practice (CoP) where members are motivated to develop a sense of identity and belonging (Wenger, 1998). Learning arises out of the act of social participation and evolves through continued engagement and collaboration (Andrew et al., 2008). Young and Mitchell (2003) identify CoP's as a valuable resource to transfer knowledge and skills within organisations. Andrew et al. (2008) suggest that nurse CoP's can challenge and change outdated care practices and disseminate new knowledge

Employee Engagement
Empowering, energising and engagement Derived from organisational psychology research, which includes: • proactive behaviour/personal initiative: taking initiative in improving current circumstances or creating new ones (Crant, 2000;Frese and Fay, 2001) • organisational citizenship: individual behaviour that is discretionary, not directly or explicitly recognised by the formal reward system, and that in the aggregate promotes the effective functioning of the organisation (Organ et al., 2005).
• contextual performance focuses on the goals of the organisation (Organ et al., 2005;West and Dawson, 2012). An engaged employee is more likely to display these behaviours, which will contribute to the effectiveness and health of the organisation above and beyond their core job roles. The King's Fund (West and Dawson, 2012) outline the elements of employee engagement: • psychological engagement (a positive, fulfilling, work-related state of mind) • proactivity, enthusiasm and initiative • organisational citizenship behaviours and organisational commitment • involvement in decision-making • positive representation of the organisation to outsiders (continued) Community of practice feeling valued and supported Promotes an ethos of learning and practice-based knowledge development through active engagement within a Community of practice (CoP) where members are motivated to develop a sense of identity and belonging (Wenger, 1998). Learning arises out of the act of social participation and evolves through continued engagement and collaboration (Andrew et al., 2008). Young and Mitchell (2003) identify CoP's as a valuable resource to transfer knowledge and skills within organisations. Andrew et al. (2008)  • Problem defining and goal setting: Feedback of the individual is accessed from peers, patients and managers, using instruments such as 360-degree assessment. Feedback stimulates reflection, develop self-awareness and challenge irrational thoughts that inhibit successful performance.
• Problem solving developing of action plans to address specific goals. Problem solving tools often include role playing, visualisation, reading material, and dialogue to help develop needed skills and attitudes.
• Transformation process: Behaviour change is achieved through self-awareness, understanding of behaviours that affect performance and generating new perceptions. The individual becomes aware of the consequences of their actions. Outcomes: maintain focus on behaviour change by creating and implementing action plans and setting goals. Seeing achievement is re-energising and motivates creativity and action. The expected outcomes include personal performance, adding value to the organisation, and for the organisation to become more successful psychological demands of the job, helping staff to fulfil caring responsibilities for family members, achieving a better work-life balance and to providing an income in late careers. Many respondents reported feeling under-valued by colleagues and managers. Older nurses and midwives wanted greater recognition of their knowledge, skills and expertise, dedication and compassion. Some respondents said they had received conflicting advice about their pensions, some were unsure about the financial impact of retire and return contracts. When staff had tried to access retire and return contacts, they found the process complicated and time-consuming. The NLNP received favourable feedback from respondents who identified the potential to support both junior and more experienced staff in the next steps of their careers and improve retention. Respondents identified two main advantages: the potential to improve job satisfaction and enable the transfer of knowledge and skills of experienced nurses and midwives to the next generations. However, some respondents raised concerns about the feasibility of the NLNP, in particular being released from their clinical duties given that services are already overstretched.
Nursing and midwifery managers and clinical leaders (n = 48) identified that late career nurses and midwives have knowledge, skills, experience, maturity and resilience which are highly valuable to the workforce and supporting more junior staff. Respondents recognised the need to re-energise late career nurses and midwives and provide opportunities for them to take up new roles, flexible working or to undertake training. Most respondents would be very interested in taking part in a future programme and some leaders were already developing their own programmes within their organisations. Respondents expressed a need to develop effective ways for late career staff to share their expertise within clinical settings and enhance the skill mix in clinical teams. Clear guidance on facilitating late career flexible employment contracts and training frameworks for late career staff were also identified as important components for improving retention of late career staff. The need to engage with late career nurses and midwives before they start making retirement plans was highlighted. Late career programmes and opportunities need to be promoted in good time to ensure nurses and midwives continue to feel motivated and valued.

Findings of NLN programme
The pilot evaluation and stakeholder feedback identified that the NLNP should be considered alongside a strategic approach to career planning, inclusive talent development and staff retention of the later career workforce (Figure 2). This supports the recommendations of the International Centre on Nurse Migration report (Buchan et al., 2018), which highlights that linking numerous policies and interventions in 'policy bundles' is likely to be more effective than single interventions for improving staff retention. The impact of the pilot programme was identified across three levels:  The RE-AIM framework (Glasgow et al., 2019) was applied to the NLNP to help consider how the programme could be evaluated and implemented in wider healthcare settings and professions (Table 4).

Discussion
The aim of the pilot programme was to develop, pilot test and refine a Legacy Nurse programme to improve the retention of the late career workforce in nursing and enhance professional knowledge translation into the clinical learning environment. In addition to achieve these aims, a scoping study and stakeholder feedback identified components of a programme which had the potential to improve retention and the quality-of-care provision. The theory underpinning the proposed programme components was explored to identify the mechanisms needed to achieve the desired outcome: energise and empower staff, develop supportive networks, facilitate knowledge transition, improve clinical outcomes and patient experience, create learning environments and career opportunities and improve the psychosocial and physical wellbeing of late career nurses.
Participants in the pilot NLNP took the lead, initiating their ideas for professional knowledge transfer and service improvement, utilising a bottom-up distributed leadership approach (Thorpe et al., 2011). Front line practitioners had protected time to learn, develop, implement change and share knowledge with others in practice. They articulated pride in their profession and positive emotions associate with the Legacy Nurse role. Pride and joy at work have been identified as central to workforce retention (NHS Improvement, 2016) and involves engaging a workforce with a positive attitude toward their organisation and its values, impacting positively on patient experience and outcomes (Perlo et al., 2017).
The NHS Staff Survey in England (NHS England, 2019a) identified that nurses and midwives who had opportunities to show initiative and make suggestions to improve their workplace had higher levels of work engagement. West et al. (2020) highlighted core workplace needs to enable nurses and midwives to deliver high-quality care: (1) autonomy -need for control over our work lives, acting consistently with work and life values; (2) belongingto be connected to, cared for, and caring of others in the workplace. Feeling valued, respected and supported; (3) contributionto experience effectiveness and deliver valued outcomes. The factors identified by West et al. (2020) were reflected in the NLNP evaluation, in particular, the concepts of connecting with fellow participants and feeling valued for their knowledge and experience were strongly expressed and valued by the participants in the pilot NLNP.
The impact of the NLNP pilot on individual, clinical and organisational outcomes demonstrate the potential of the programme to benefit the wider workforce, if they are implemented within a range of multi-level strategies over a sustained period of time. Any programme of development must operate from within the organisational culture in which it is situated. In England, the NHS is facing unprecedented challenges following the first and second waves of the Covid-19 pandemic. Pressures on the NHS have been compounded and exacerbated by longstanding issues including Baseline, mid-point, post-programme and longer terms evaluations of outcomes should include qualitative and quantitative data and incorporate findings from regional/national data sets where possible (Staff Surveys). Impact assessments of the programme should also capture the impact of individual projects and role development. Identify ways to remain in contact with Legacy nurses and midwives to enable long-term evaluation (career progression, leaving or remaining in in employment) Adapted from the UPSTREAM program funded by the Colorado Health Foundation; the Evaluation Hub of the University of Colorado Department of Family Medicine. chronic excessive workload, inadequate working conditions, staff burnout and inequalities, particularly among minority ethnic groups (King's Fund, 2020). Institutional racism has been exposed despite the NHS having one of the most ethnically diverse workforces (Ross et al., 2020). Lack of staff development and supportive networks have been highlighted as barriers to career progression and contribute to negative experiences of ethnic minority NHS staff. Therefore, a central consideration for future programmes is ensuring access and inclusion of late career nurses from ethnic minority backgrounds. Organisations need to make a concerted effort to retain and value the professional knowledge and experience of registered nurses who face discrimination and challenges at a disproportionate rate to their white colleagues (Ross et al., 2020).

Limitations
This was a small pilot study which only included six nurses so the findings may not be transferable to nurses in different contexts. However, further consultation from 238 stakeholders was sought to inform the recommendations. As part of the implementation plan, a larger evaluation is required in different sites and settings to identify how the programme performs and the refinements and adaptations needed for different settings and participants. Although the pilot only lasted 6 months, all participants continued to receive mentorship to help their transition back into practice areas and identify career development opportunities. Wider implementation (phase 2) is now underway across the local integrated health and social care system to include wider care settings, nurses, midwives and allied health care professionals. Recognising the context, post first and second wave of the Covid-19 pandemic and the additional work stressors on staff, further stakeholder engagement is underway to assess the impact of the pandemic on late career healthcare professionals and their career intentions. This includes impact on the health and wellbeing of staff, alongside workforce performance, retention outcomes and further consideration of sustainable supportive interventions.

Conclusion
A pilot programme was developed and evaluated in a small cohort of Legacy Nurses and independent evaluation was positive from the nurse participants, managers and facilitators. Programmes aimed at retaining late career nurses are already being implemented in various healthcare settings internationally. However, there is a lack of evidence-based programmes and the need for further evaluation and an effective and sustainable programme. The components of communities of practice, engagement and coaching have the potential to address late career nurses needs and enable them to share their professional knowledge and skills within clinical teams.
The critical nursing workforce context has been further exacerbated by the Covid-19 pandemic. To address the need for restoration and recovery and the workforce required for transformation to deliver on the NHS Long Term Plan (NHS England, 2019c), employers are seeking to adopt new roles and flexible ways of working to retain nurses. There is an even greater requirement to focus on the retention of a workforce who have experienced unprecedented pressures. The NLNP was seen by the participants as a way of addressing a lack of a formal career path for experienced clinical nurses. The information from the evidence base, stakeholder engagement and the underpinning theory of the supporting mechanisms for late career nursing was accessed to make recommendations for the components of a Legacy Nurse programme, with a recommendation that this model should be further tested and expanded to include midwives and other allied health care professionals in different healthcare contexts.

Key Points
• Retaining late career nurses and midwives within health and social care is a critical global workforce priority. • The NLNP has the potential to provide an innovative solution to workforce retention, recognising, valuing and retaining professional clinical knowledge and skills. • In light of the first and second wave of the Covid-19 pandemic, additional stressors now facing the health and social care workforce and the potential impact on retention requires further research • The programme requires further development in the post Covid-19 restoration and recovery phase, with wider testing and evaluation in various clinical settings. It should be considered as part of an integrated approach to workforce planning and inclusive talent development. • To support late career nurse retention and the NLNP, an informed and more consistent approach to providing financial and pensions advice is required to support nurses and midwives considering their employment, flexible working or retirement options. • Opportunities for career planning should be introduced and encouraged in early careers and revisited throughout the nursing career pathway.

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work-based development programme was funded by Health Education England, Midlands and East.

Ethical permissions
The programme was agreed to meet the criteria for a service development/quality improvement project and ethical permission was not required.