Executive Summary, Recommendations and Key Messages
Introduction and background
The aim of the Commission was to maximise opportunities to participate in nursing and midwifery education and careers. It formed part of wider work to ensure Scotland's nursing and midwifery workforce is sustainable and fit for the future, with the right numbers, the right training, the right skills, the right opportunities, and the right support. The Chief Nursing Officer ( CNO) commissioned Professor Paul Martin, CBE, Depute Principal, University of the West of Scotland, to chair a review process and submit a report.
The Commission's observations and recommendations
Celebrating the impact and opportunities of nursing and midwifery education and careers
A career in nursing and midwifery creates a positive and rewarding opportunity to contribute to the wellbeing of individuals, their families and communities in Scotland and beyond. It is clear that a solid foundation of interest in accessing such careers remains, but there is also evidence of a negative perception of them, based on reward, pressures and intensity, that need to be contextualised and balanced with the extensive opportunities for career progression and personal and professional satisfaction. Creating a more positive yet realistic narrative will not only support interest in nursing and midwifery careers, but will also enhance general understanding of the roles and their contribution to health and social care provision. A campaign to forward this aspiration should be viewed as an investment, rather than a cost; it will position nursing and midwifery as confident and optimistic professions that underpin the functioning of health and social care in Scotland.
1. In line with the Nursing 2030 Vision of promoting confident, competent and collaborative nursing for Scotland's future, a national campaign (incorporating and building on the output of previous work on the Extraordinary Everyday campaign) must be commissioned. The campaign should:
- be designed around the needs of different audiences (such as young people, higher tariff-point students, mature students, men, people from disadvantaged communities, people with disabilities and people from ethnic minority communities)
- reflect the diversity of Scotland's population and promote diversity in the nursing and midwifery workforce
- emphasise the professions' flexibility and extensive opportunities for personal and professional development
- recognise nursing and midwifery career opportunities beyond the traditional boundaries of NHS Scotland
- tackle stereotypical images of nurses and midwives, creating a more positive professional role model.
2. In relation to attracting men to the professions, CNO should scope current best practice in this area and make recommendations for a national approach with realistic targets.
Flexible access to nursing and midwifery education and careers: making it happen
The Commission identifies a complex set of articulation  and flexible access arrangements that are not readily understandable to people seeking to access the education pathway nor, it would appear, to the collective institutions. This, it would seem, results in duplication of effort, commitment and cost for individuals, education institutions, employers and education funders. These observations link to the Review of the 15-24 year old Learner Journey and the recommendations should be further informed by the outcome of this review.
The Commission's recommendations reflect its concerns about the – at times – incomprehensible nature of the education journey for, in particular, those seeking flexible access to nursing and midwifery education and careers. The complexity made it difficult even to have clarity on the national picture, as regional differences are apparent. This made developing a new proposed route map beyond the scope of the Commission, but it should be an urgent action for development.
Although the Commission notes the review of standards for nursing and midwifery education by the Nursing and Midwifery Council ( NMC), it is concerned about the lack of flexible access (specifically to midwifery programmes) that may compromise extremely capable people, such as maternity care staff, seeking access to the midwifery degree programme.
The Commission has identified the apprenticeship route as being a vehicle that could positively contribute to flexible access to nursing and midwifery education. It was unanimous in its position that nursing and midwifery should remain graduate professions and that this should not be compromised. That said, the Commission also explored the idea of 'graduate versus graduateness', in that the added value of a higher education degree-based outcome is manifest in the graduate attributes the person acquires through the education journey. There is no doubt that this can be achieved in different ways through flexible pathways.
Scotland needs to explore how to build on the use of apprenticeship frameworks in the social care sector to fully capitalise on their potential to support a highly-skilled, vibrant and dynamic health and social care workforce, both now and in the future. In particular, the Commission recognised that the apprenticeship model may fit with the preparation of support workers and the journey to nursing and midwifery registration, including, but not exclusively, promoting access from traditionally underrepresented and lower participation demographic groups, such as people in remote and rural communities.
Emerging data on completion rates and Scottish Index of Multiple Deprivation ( SIMD) show that students in SIMD1 (those from the 20% most disadvantaged communities in Scotland) are less likely to complete and take longer to complete than students from other SIMD categories. Further exploration of this data should be a key priority for taking forward actions from the Commission.
3. A working group should be commissioned to develop a common articulation framework for nursing and midwifery education in Scotland, building on the existing Scottish Credit and Qualifications Framework ( SCQF). As nursing and midwifery practice and education consider the implementation of revised NMC standards, it is imperative that a once-for-Scotland approach is taken, with a discrete focus on widening participation forming part of full implementation.
The framework should:
- enable flexible entry and exit to the framework at designated points, with recognised outputs
- ensure that recognition and application of recognised prior learning ( RPL) is applied consistently across all HEIs to support access and entry to undergraduate nursing and midwifery studies
- explore opportunities for integrated inter-professional learning for the health and social care workforce
- recognise that individuals may access it from an increasingly complex provider landscape
- include a nationally agreed progression route for nursing and midwifery support workers.
4. The SIMD profile of students varies considerably across HEIs. Steps should be taken through commissioning frameworks to ensure that widening participation SIMD targets are met across all HEIs; this will need to be done at individual HEI level to reflect the current position and the differences between nursing and midwifery student populations.
5. NHS boards and other employers in the health and care sector should consider opening access to Scottish Wider Access Programme ( SWAP) routes to nursing for support workers, in addition to the current Higher National Certificate ( HNC) route.
6. Consideration should be given to extending the approach set out in the Scottish Government-funded Open University ( OU) pilot in Grampian for widening participation in nursing education to help increase development opportunities for support workers in the health and social care sector, if found to be productive.
7. Further clarification of health and social care foundation apprenticeships is required to establish a recognised route from school into pre-registration nursing and midwifery programmes and, more broadly, into the wider health and social care professions.
8. Further exploration and active targeting with a view to increasing the profile of apprenticeship models and their applicability to widening participation in nursing and midwifery education and careers should be conducted, reflecting in particular underrepresented groups and exploring evidence emerging from elsewhere in the UK. Particular attention should be paid to clarifying how staff engaged on apprenticeship pathways within the service can navigate onto nursing and midwifery programmes (including any additional qualifications and prerequisites candidates may need to be supported to articulate onto higher education institution nursing and midwifery programmes).
9. The graduate apprenticeship model should be further explored to examine its fit into the pathways to nurse and midwifery registration. The Commission suggests that the OU would be well placed to take this work forward.
10. Findings from the Review of the 15–24 Learner Journey programme of work should be considered and implemented in relation to nursing and midwifery education.
The Commission recognises that some of the changes described in this report will require time, effort and focus to deliver. The commissioning framework available to CNO for pre-registration nursing and midwifery education can, in this context, be used as a positive lever to effect and support change. It is accepted that such an approach may be perceived as overly prescriptive, but the Commission's view is that a positive approach to commissioning will be an essential lever in delivering some of the key changes called for in the report. In effect, for a period, positive commissioning equals positive change.
The Commission also reflects concerns raised about the, at times, ad-hoc nature of the pre-registration commissioning process in the context of the broader levers available through flexible pathways to pre-registration education. The Commission therefore is strong in encouraging continuation of the current multi (three-year) rolling approach to commissioning of pre-registration nursing and midwifery training places.
The Commission also noted the requirement for a more comprehensive and contemporary approach to workforce planning across health and social care, which builds on the concept of zero-based workforce planning.
11. CNO should adopt a positive approach to commissioning pathways to pre-registration education for nursing and midwifery that would:
- extend existing routes into nursing for support workers, including the HNC and OU options
- open up availability of the existing funded HNC option to all support workers in health and social care
- review and potentially refresh existing funding for HNC employer backfill arrangements
- recognise the need to support employers across the health and social care sectors as they construct flexible support arrangements that enable staff such as support workers to articulate into pre-registration programmes
- respond to the widening participation challenges already evident in the sector, ensuring equality and diversity requirements are championed
- review financial support for students, including the Nursing and Midwifery Student Bursary, means-tested discretionary funds and access to loans from the Student Loans Company
- review and consider additional targeted support for students undertaking the OU programme, with a particular focus on students from remote and rural areas.
12. CNO should explore with workforce colleagues the concept of zero-based workforce planning in modelling service delivery and demand for the future and take a fresh and at times radical approach to defining and describing the workforce required to address anticipated needs.
13. The review of nursing and midwifery student support should be completed, ensuring a strong focus on widening access to nursing and midwifery education.
The shared aim of CNO and all involved in the Commission's processes is to achieve a highly skilled, ambitious and sustainable nursing and midwifery workforce that is responsive to the challenges of providing high-quality, safe and person-centred care for Scotland's communities.
The Commission recognises that there are a range of policies already in place to support nursing and midwifery education. However, Scotland faces challenges in recruiting to nursing and midwifery education and careers. It is not alone in this regard – as the rapid review of UK and international literature requested by the Commission shows, many countries find themselves in similar situations. But the fact that the problems are common, and that many of them are very challenging to face down, does not provide an excuse not to confront them. That is why CNO set up the Commission, and it typifies the spirit in which the Commission set about its task.
Action in this area requires partnership-working to produce national, flexible and transferable education and employment solutions.
CNO needs to ensure that evidence of the impact of actions based on the Commission's observations and recommendations can be collected, so that each action can be reviewed in a few years' time. Some mechanisms for collecting evidence of impact already exist, while others may have to be created. The key principle, though, is that without evidence, incorrect assumptions about effects might be made.
The aim of the Commission has been to build on what is working well in Scotland, develop it if possible, and change what is not working well. Action on its observations and recommendations will, the Commission feels, achieve that aim, and is vital to the future of the nursing and midwifery workforce and the wider design and delivery of health and social care services in Scotland.
Key Messages from the Commission
1. While NHS workforce numbers have never been higher, there is a need to take action now to ensure the right numbers of staff with the right skills are available to provide high-quality health and social care services to the people of Scotland now and in the future.
2. The perception of nurses and nursing is stuck firmly in the past and was found to be ingrained in the public consciousness from as early as primary school. This suggests that updating and enhancing the public image of nursing roles could deliver significant benefits for recruitment. By contrast, the midwifery profession enjoys a comparatively modern image.
3. The regulatory system for registered healthcare professionals is complex, cumbersome and expensive. Parallel arrangements for the regulation of support workers in health and social care are seen to impact on widening participation to nursing and midwifery, particularly for people working in social care settings.
4. Nursing (and, to a lesser extent, midwifery) is doing fairly well in developing measures to widen participation in areas such as socioeconomic background, but less well in relation to gender; further work is needed to understand progress in relation to ethnicity and disability. The professions are nevertheless making substantial contributions to helping higher education institutions meet their widening participation targets.
5. The Commission is concerned about the lack of flexible access (specifically to midwifery programmes) that may compromise extremely capable people, such as maternity care staff, seeking access to the midwifery degree programme.
6. There is currently no national framework to govern articulation into nursing and midwifery programmes. A national single framework for articulation routes would help service providers and further and higher education institutions ensure that programmes are fit for purpose and meet local needs.
7. There is inconsistency across higher education institutions in Scotland on recognition of vocational and other qualifications, and prior learning, in relation to articulation into nursing and midwifery programmes.
8. Potential students from the care home sector and remote and rural locations do not enjoy equitable opportunities and access to nursing and midwifery courses and support.
9. Current routes into nursing that have existed for some years but currently lie dormant or are used inconsistently need to be re-energised through positive commissioning and potentially an injection of new funding.
10. Current student support mechanisms, such as the Nursing and Midwifery Student Bursary, continue to play a vital role in supporting access to education, but may not be targeted sufficiently on widening participation aspirations.
11. To support the undoubted benefits of widening participation to nursing and midwifery programmes, education pathways need to reflect the diversity of ability of the workforce and students, and ensure programmes support success.
12. Widening participation needs to also include a focus on attracting and recruiting higher tariff-point students, particularly to nursing programmes.