The CNO Commission on Widening Participation in Nursing and Midwifery Education and Careers: Final Report

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Acknowledgement

The Commission is grateful to the authors of the following two reports, information from which is cited within the main text.

CNOWA Rapid Review of the Literature – Policy and Practice, by Dr Maria Pollard and Margo Stewart, University of the West of Scotland, and Allan Gillies, NHS Education for Scotland.

Hearing the Student Voice: accessing nurse education through widening participation routes, by Dr Rosie Stenhouse, University of Edinburgh.

Foreword by the Chief Nursing Officer

Efforts on widening participation to education and careers have been relatively successful in nursing and, perhaps to a slightly lesser extent, midwifery in recent years. However, in common with the rest of the UK and internationally. Scotland nevertheless faces challenges in recruiting to the professions at a time when we are rich in people, both young and experienced, who want to become nurses and midwives.

The most sensible and productive way to address this issue was to bring together a wide-ranging Commission, comprising representatives from all interested stakeholders, to review the current situation in Scotland and elsewhere, evaluate the evidence on what approaches to widening participation in the nursing and midwifery professions work (and which do not), and come up with some recommendations for us to consider as we move this agenda forward.

The aim was to ensure the right numbers of people with the requisite qualities and competencies enter nursing and midwifery education, complete their courses then enjoy long and satisfying careers as registered practitioners in the NHS and/or social care sector (particularly in remote and rural locations and in care homes) in Scotland. Although the Commission has sought to surface and, where possible, address concerns, importantly the focus has also been on identifying what we are doing well in Scotland and how we can build on this.

More broadly, the Scottish Government has committed to taking measures to ensure that the entire workforce in Scotland, including young people, is equipped with the skills they need to find meaningful employment in today's economy; and to widen access to higher education. Given these wider policy imperatives, it was also vital for the Commission to define more clearly how the nursing and midwifery professions are currently contributing to these wider employability and higher education agendas and to reflect on what their contribution needs to be in the future.

The Commission would need strong and committed leadership to guide it through what would inevitably involve some challenging discussions. No one is better placed to do so than Professor Paul Martin. As a registered nurse, health visitor and midwife, former NHS chief executive, distinguished Chief Nursing Officer for Scotland and now Depute Principal at the University of the West of Scotland, Professor Martin has the service, policy and education experience and insight needed to undertake this challenging but vital task. He also has the personal qualities to bring people together in common cause, provide the licence and encouragement to allow stakeholders to think ambitiously and, ultimately, support people to develop a shared idea to shape the path ahead.

I was delighted that Professor Martin accepted my invitation to chair the Commission, and thank him, his project team, the Commission's Stakeholder Group and the wider agents who engaged with the work for delivering a clear, evidence-based case for widening participation in nursing and midwifery education and careers in Scotland.

Professor Fiona McQueen
Chief Nursing Officer
Scottish Government

Foreword by the Chair of the Commission

As Scotland reshapes its health and social care services to meet the changing needs of its people there are, and will continue to be, changes in the required competency, capability and capacity of the workforce to support these new and different services. However, at the heart of any care provision will be the role of nurses and midwives. This does not exclude them from the change agenda. Indeed, many of the changes are driven by growing recognition of the impact of quality care on outcomes for people who need this support. Where a nurse or midwife is needed and where they add value is exactly where they should be. This therefore promotes person centredness – not just in direct care, but also in service construct.

It is therefore essential that as the demographics of Scotland change, we are positioned to respond with the right number of nurses and midwives, with the right skills, in the right place, doing the right things.

This Commission from the Chief Nursing Officer to explore the challenges and opportunities to encourage and support widening participation in nursing and midwifery education and careers could not be timelier. There are recognised pressures on flow into the health workforce. There are areas where nurses and midwives are difficult to recruit – not just by region, but in clinical and service specialties and, particularly, in care homes. Add to that a change agenda in health and social care, the repositioning of acute care, the age profile of the workforce and let's not forget Brexit, and it is clear there are pressures that need solutions now and, importantly, that plans are created and implemented for the future.

This report seeks to surface and where possible address some of these concerns. It should be read in the context of the wider health and social care and education agendas. The actions and recommendations will make a difference and encourage opportunity and flexibility, promoting participation in nursing and midwifery careers.

At the heart of this report rests an understanding of what nursing and midwifery offer as professions, careers or vocations. The opportunities are considerable and exciting, from the support worker to the nurse or midwife consultant, from the Higher National Certificate student to the doctoral studies student.

From staff nurse to executive nurse director or, indeed chief nursing officer level, nurses and midwives influence every corner and aspect of health and social care and are to be applauded for their efforts and commitment. This was evident in the student and early-career nurses and midwives who participated in the work of the Commission. They were indeed inspiring and if the future is in their hands, then I am grateful.

I would like to thank the members of the Commission and the project team for their patience and hard work and commend the observations and recommendations of the Commission to you.

Professor Paul Martin, CBE
Chair of the CNO Commission on Widening Participation in Nursing and Midwifery Education and Careers

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.

Recommendations

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 NHSScotland

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 articulation¹ 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.

Recommendations

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.

Positive commissioning

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.

Recommendations

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.

Conclusion

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.

Introduction

While efforts on widening participation to education and careers have been relatively successful in nursing and, perhaps to a slightly lesser extent, midwifery in recent years, Scotland nevertheless faces challenges in recruiting to the professions.

Applications for nursing and midwifery courses have been falling, albeit only in some areas and fields of nursing. Numbers of men expressing interest in careers in the professions have reduced, and the public image of nursing and midwifery needs to be updated to ensure that candidates coming forward for careers in the professions have a better understanding of what their experiences will actually encompass.

In nursing, initiatives launched elsewhere in the UK and internationally and societal changes here in Scotland are questioning what a nurse will look like in the years to come. This is being addressed through the Nursing 2030 Vision initiative,² which sets the direction of travel nursing needs to follow.

The care home and wider care sector, which provides such a vital service to Scotland's communities, is also facing recruitment challenges. The sector is seeking solutions by trying to find ways to encourage more registered practitioners to commit to, for example, care home nursing to help the service develop and improve.

These factors, and others, signalled that action is required to ensure a sustainable nursing and midwifery workforce for now and the future to ensure the right numbers of people with the requisite qualities and competencies enter nursing and midwifery education, complete their courses then enjoy long and satisfying careers as registered practitioners in the NHS and/or social care sector (particularly in care homes) in Scotland.

The Chief Nursing Officer's (CNO's) ambition is to maximise opportunities to access nursing and midwifery education and careers through offering appropriate support, widening participation strategies and providing flexible pathways, with the aim of meeting projected needs for nurses and midwives as outlined in the National Health and Social Care Workforce Plan Part 1³ (see Section 3.1.1).

For the purposes of the Commission, 'widening participation' is defined as: widening opportunities for people not only to access education in nursing and midwifery, but also to engage in careers in, or associated with, the professions. Widening participation to nursing and midwifery therefore relates to a wide range of people with diverse social characteristics and from a variety of backgrounds. This includes young people, higher tariff-point students, mature students, men, people from disadvantaged communities, people with disabilities and people from ethnic minority communities. It also takes into account people who wish to learn on a part-time or distance basis and those already engaged in, or about to embark upon, a vocational route.

To achieve the ambition, CNO commissioned Professor Paul Martin, CBE, Depute Principal, University of the West of Scotland (UWS), to chair a review process and submit a report that sets out:

a shared understanding of the routes to accessing nursing and midwifery education, the barriers that may exist and the opportunities for their removal

recommendations on actions and targets to improve access to nursing and midwifery education and careers and strengthen a culture of partnership among schools, colleges, universities, employers, NHS Education for Scotland (NES), the CNO Directorate and the wider Scottish Government, with each recognising the role it can play in improving access to nursing and midwifery careers and working in partnership to achieve this.

This final report is set out in three main chapters.

1. The Commission, describing the Commission's aims, strategic drivers and processes.

2. Evidence and findings, setting out the data that underpins the Commission's observations and recommendations. The chapter looks at the nursing and midwifery workforce, pre-registration nursing and midwifery education, access routes (both to general and nursing and midwifery education), and funding and support (again, for education generally and nursing and midwifery education specifically). It also includes a rapid review of the international literature, the results of a survey carried out on the Commission's behalf of students and registered nurses, and examples of emerging approaches in Scotland.

3. Observations and recommendations, presenting the Commission's observations and recommendations across three key areas:

Celebrating the impact and opportunities of nursing and midwifery education and careers

Flexible access to nursing and midwifery education and careers: making it happen

Positive commissioning.

The National Health and Social Care Workforce Plan Part 1 signalled challenges across the NHS and social care workforce. While the Commission's work focused on nursing and midwifery, it is hoped that some of its outputs may be generalised across the entire health and social care workforce.

1. The Commission

This brief chapter describes the Commission's aim, strategic drivers and processes.

1.1 Aim of the Commission

The aim of the Commission was to maximise opportunities to participate in nursing and midwifery education and careers, identifying best practice and barriers to entering the professions through engagement with potential and actual students, nurses, midwives and key stakeholders. 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 recently published Nursing 2030 Vision reaffirms this commitment and highlights that the Commission's observations and recommendations will play a big part in determining approaches to maintaining and improving access – and consequently ensuring an ongoing and sustainable supply of nurses – as we move towards 2030. The Best Start⁴ five-year forward plan for maternity and neonatal care in Scotland likewise commits to reconfiguring the existing midwifery and obstetric workforce to support continuity of care for women, noting that it is particularly essential for staff in remote and rural areas to be able to access high-quality education, training and support.

1.2 Strategic drivers of the Commission's work

The Scottish Government has committed to taking measures through its Plan for Scotland: the Government's Programme for Scotland 2016–17⁵ to ensure that the entire workforce in Scotland, including young people, is equipped with the skills they need to find meaningful employment in today's economy. General measures include:

increasing the number of modern apprenticeships with the aim of securing 30,000 per year by 2020, and widening access to modern apprenticeships to people with disability, those from ethnic minority backgrounds and young people who have been in care

developing proposals to implement a new Jobs Grant for 16–24-year-olds returning to work after six months' unemployment

continuing to fund local authorities to deliver the Opportunities for All commitment, which offers an appropriate place in learning or training to all 16–19-year-olds

supporting 11,650 places through the Employability Fund

working towards a reduction in youth unemployment of 40% by 2021 through the Developing the Young Workforce strategy

developing and implementing new services to help people find and stay in work by better aligning employability support to encourage sustainable and fair work and focus support on those who need most help.

In relation to health and social care, key strategic drivers include the Health and Social Care Delivery Plan⁶ and the National Health and Social Care Workforce Plan Part 1.

The Commission worked within a wider – and evolving – economic, employment, education, and health and social care policy landscape, and positioned its work within, and took active account of, the implications of the Developing the Young Workforce Strategy,⁷ the final report of the Commission on Widening Access, A Blueprint for Fairness,⁸ the ongoing Review of the 15–24 Years Learner Journey, youth employment strategies and the Apprenticeship Levy. Wider reviews of student support in Scotland and nursing and midwifery student support from 2018/19 were also ongoing and relevant to the review process.

As an Impact for Access project funded by the Scottish Funding Council (SFC) reported in October 2017,⁹ the First Minister's goal is to increase the proportion of people from the 20% most deprived communities in Scotland (SIMD1) entering full-time HEI degree courses in Scotland by (at least) 16% by 2021, 18% by 2026 and 20% by 2030, and to ensure at least 10% of all entrants to HEIs in Scotland come from SIMD1 postcodes by 2021. The Commission was cognisant of this aspiration throughout its term.

1.3 Overview of the Commission's approach

The Commission was Chaired by Professor Paul Martin, CBE, and was supported by a core project team consisting of Scottish Government and NES staff and colleagues from UWS. It used a combination of methods to gather evidence from a diverse range of sources, including collating relevant information and data, reviewing available evidence and literature, commissioning a rapid review of the international and UK literature (see Section 2.5) and a survey of students and registered nurses (see Section 2.6), and engaging with the Commission's Stakeholder Group, other key stakeholders and subject experts.

The project team identified five broad themes to help structure the review process. These reflect the themes of the Review of the Learner Journey and are as follows.

1. Learner Choice and Application – improving information, advice and application processes

2. Learner Choice and Application in Colleges and Universities – improving information, advice and application processes

3. Access and Application – improving the ease with which people can apply to colleges and universities

4. Provision Transition/Progression – improving the design, alignment and coherence of the learning journey and subsequent career pathway

5. Funding – improving the learning system and career pathway and removing unnecessary duplication.

The project team also worked with the Scottish Government Strategy Unit and Ingage teams to apply methods such as storytelling, Rapid Reflection (see Section 1.5) and systems mapping. This allowed the Commission to challenge preconceptions and map the system as it currently exists.

The overall approach enabled the Commission to build an inclusive and comprehensive picture of current pathways into nursing and midwifery education and careers and how they are experienced; from there, it was able to identify what is working well and where blockages lie, and make observations and recommendations to strengthen the former and mitigate the latter.

1.4 Engagement strategy

A wider engagement strategy was developed to ensure an inclusive approach and to gather system-wide and multi-sectoral experience and insights.

The Stakeholder Group had representatives from nursing and midwifery professional bodies, health and social care employers, higher and further education bodies and representative groups, national organisations and Scottish Government officials (membership is set out in Annex 1). The Group met at three full-day workshops in June, August and October 2017, and individual members engaged directly with the project team on an ongoing basis. Members were actively involved in shaping the observations and recommendations that appear in this final report.

A key priority was to engage with and hear from people with direct experience, including those who have taken steps towards – or had embarked upon – nursing and midwifery education or careers, as well as those who have chosen alternative paths or decided to leave nursing and midwifery education. To this end, a series of focus groups was held with people with direct experience.

Current nursing and midwifery students from a diverse range of backgrounds took part in the Stakeholder Group's first workshop to provide personal experience of accessing education and progressing into the nursing and midwifery workforce. Focus groups were conducted to explore students' and support workers' perceptions of nursing and midwifery education and careers, barriers and enablers, and potential future support, the result of which was a report prepared for the Commission by Dr Rosie Stenhouse of the University of Edinburgh into students' experiences of accessing nurse education through widening participation routes. Some of the observations from this report, which had a strong influence on the Commission's deliberations and actions, are set out in Section 2.6 and elsewhere in the text.

CNO and the Commission's Chair were committed to ensuring that everyone involved in this process had an equal voice, be they a potential or current nursing and midwifery student or someone with a well-established career.

1.5 Rapid Reflection methodology

The Commission's approach was informed by the Rapid Reflection methodology, which guided the Commission's work throughout the process.

The Rapid Reflection model is described as a thinking tool that consists of a large-scale infographic and an accompanying structured collaborative discussion process. It provides decision-makers faced with difficult policy challenges with a strategic framing of the context and consequences of the issue in question. A rapid immersion into the big picture allows for a better understanding of what the challenge may mean and helps inform strategic policy-making going forward. The model overcomes the limitations of traditional knowledge transfer by constructing and presenting information in an easy-to-understand and highly visual strategic framework.¹⁰

The Commission's Stakeholder Group began an initial appraisal of key issues, uncertainties and pressures using the Rapid Reflection methodology at its first workshop in June. The Situation Report developed through the methodology, which allowed stakeholders to look not only at the current situation, but also consider the wider historical context and 'back story' underpinning the Commission's task, focused on key issues, pressures and uncertainties identified by the Stakeholder Group. It was refined at successive Stakeholder Group workshops.

2. Evidence and findings

The Commission gathered a range of information regarding Scotland's nursing and midwifery workforce and student population profiles, existing access routes, and policies and measures encouraging access to education and employment (including financial support for institutions, employers and students). The following provides a brief overview and key headlines, with some examples of emerging approaches to widening participation in nursing and midwifery careers being taken forward currently in Scotland.

The chapter also provides summaries of two pieces of work carried out on the Commission's behalf: a rapid review of the international and UK literature, and a survey of students and registered nurses on accessing nurse education through widening participation routes.

2.1 Nursing and midwifery workforce

Nursing and Midwifery Council (NMC) registration figures¹¹ show that as of March 2017, there were 618,863 registered nurses and 33,464 registered midwives on the UK register.¹² In Scotland, 68,826 nurses and midwives were on the register in September 2017.¹³

Fifteen per cent of the workforce in Scotland are employed in health and social care, representing over 400,000 staff. Around £6 billion is spent annually on the 162,598 staff employed by NHSScotland, and 99.6% of all NHS care is delivered by NHS staff.

The nursing and midwifery workforce is the largest staff category for NHSScotland by some way (42.7%), with almost 60,000 whole time equivalent (WTE) nursing and midwifery staff in employment in June 2017. Overall, there are more than 3,000 WTE more nursing and midwifery staff working in NHSScotland compared to five years ago.

Since September 2006, the number of registered nurses and midwives working in NHSScotland has increased by 5.6%, by 2,314.0 WTE to 43,340.2 WTE. At June 2017, 73% (40,956 WTE) of the NHSScotland nursing workforce was registered, a proportion that increased by 0.9% over the past decade. Information and Statistics Division (ISD) figures show that 83% (2,347 WTE) of the midwifery workforce was registered as of September 2016 (a reduction of 5.9% from September 2007, while midwifery support staff WTEs increased by 83% over the same period). Workforce planning requirements in light of a transformed model will be part of the work to support implementation of the Best Start review. This will include the need to consider the role of support staff.

In relation to the social care sector, there were around 6,650 nurses working in the social services sector at the end of 2016, representing about 10% of the nursing workforce in Scotland. The independent sector employs 6,051 (91%) of social care nurses across care home services for adults, housing support and care at home services. Care homes for adults employ 64% of this total.¹⁴ Eleven per cent of the total (registered and support staff) nursing workforce is male, but males account for under 1% of the midwifery workforce. The nursing and midwifery student population is currently 92% female and 8% male, and the proportion of males applying to nursing is falling. The workforce is also ageing.

The National Health and Social Care Workforce Plan Part 1 identifies current and future workforce challenges, including the effects on the nursing and midwifery workforce of issues such as remoteness and rurality, availability of nurses in social care (in particular, care homes), and the potential effects of the UK's exit from the European Union (Brexit). It considers international flows, including the impact of Brexit, on recruitment and retention, and how to make more effective use of international recruitment opportunities. These will take account of developing research across the wider public sector in Scotland of the potential effects of Brexit on international recruitment.

It is not possible to know exactly what effects Brexit will have on the nursing and midwifery workforce at this stage, but registration data show that the number of initial joiners to the NMC register from EU countries reduced from 9,389 in 2015/16 to 6,382 in 2016/17; total numbers of EU registrants nevertheless rose from 34,502 in March 2016 to 38,024 in March 2017.¹⁵

The National Health and Social Care Workforce Plan Part 1 projects a shortfall of qualified nurses and midwives in the short and medium term unless further measures are taken to enhance supply and manage demand. It commits to an estimated 2,600 additional nursing and midwifery training places by 2021, alongside a wider package of measures to support recruitment and retention of students and existing staff, and measures to widen participation in education and careers. Further work is being undertaken to define nursing and midwifery numbers within the aggregated headline figure.

The National Health and Social Care Workforce Plan Part 1 sets out key recommendations for all of the workforce that relate to:

testing out new approaches, focusing on promoting and attracting applicants and making health and social care careers more attractive to young people through improved marketing and advertising

exploring the interface between health and social care and further and higher education to maximise opportunities to recruit and retain staff

linking student commissioning more closely to recruitment, retention and youth employment, taking account of current trends in supply and demand; this work should also link to career paths and opportunities across the health and social care sector.

These recommendations reflect the situation that while NHS workforce numbers have never been higher, the 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 is urgent.

The Commission noted that efforts to forecast future demands for the nursing and midwifery workforce in capability, competency and capacity terms require further work. This should include the modelling of workforce against future models of care delivery. The concept of a zero-based workforce planning approach was explored and should be tested further.

2.2 Pre-registration nursing and midwifery education

At 31 October 2016 (the last available data at the time of the report's publication), there were 10,239 students in pre-registration nursing and midwifery education, of which 539 were student midwives.¹⁶ The recommended increase in student nursing and midwifery intakes for 2017/18 was 4.7% – the fifth successive rise (following a 5.6% increase in 2016/17, 3.5% in 2015/16, 6.6% in 2014/15 and 4.1% in 2013/14), equating to 3,360 entry places; 60 additional places over and above existing numbers were funded in north-east Scotland to reflect the challenges experienced in remote and rural areas.

Nursing and midwifery pre-registration programmes in Scotland continue to be over-subscribed, but the number of applications per place has fallen in recent years, and Scotland has seen a 10% reduction in applications from males since 2013. There was an aggregated 3.2% reduction in applications to pre-registration nursing and midwifery programmes from students domiciled in Scotland to Scottish universities between 2016 and 2017. By contrast, English universities saw a 22.9% reduction in applications from students domiciled in England during the same period.

Scottish higher education institutions (HEIs) had the highest median percentage of nursing graduates in sustained employment at one year (75.8%) and three years (68.5%) after graduation compared to all other regions across the UK, and the second highest median percentage of nursing graduates in sustained employment five years (67.1%) after graduation (the highest was East Midlands, at 68%). There are nevertheless significant differences in performance across HEIs and nursing fields.

Scotland is performing well in attracting students over the age of 25, while England in particular has seen a substantial drop (23%). Though the nursing and midwifery student intake is one of the most age-diverse, it nevertheless remains largely under the age of 24. Currently, around 48% of students are under 20, with about 28% between 20 and 24.

HEIs' and further education institutions' (FEIs') contextual admission targets include objectives against the SIMD (including, for example, SIMD1, representing the 20% most deprived areas of Scotland). The Impact for Access project funded by the SFC that reported in October 2017¹⁷ showed that 14% of Scottish-domiciled entrants to full-time degree courses in Scotland's 18 HEIs in 2015/16 came from SIMD1 postcodes, suggesting the national 16% target by 2021 is within reach. The percentages differed significantly among institutions, however, for those HEIs offering nursing and midwifery education, they ranged from around 27% to just above 5%.¹⁸ At 3.5 years after starting a nursing programme, there is an approximately 15 percentage point difference in probability of completing between students from the most deprived communities (54%) and those from the least deprived (69%); by five years after starting, this gap has closed to 6 percentage points (77% and 83% respectively).

On gender diversity, there has been a slight reduction in the proportion of male students applying to pre-registration nursing and midwifery courses: 8% of the 2016 student cohort was male. Data has shown women are more likely to complete their courses.

Around 95% of students are UK nationals, with most non-UK nationals coming from European Economic Area (EEA) countries. In 2017, Scotland was the only UK country to see a rise in EEA students applying to nursing (+3%).

A summary of information on the nursing and midwifery pre-registration student population is shown in Table 1.

Table 1. Pre-registration nursing and midwifery student data in Scotland

INDICATOR
Nursing (all fields)
Midwifery

Applications (source: UCAS)
Numbers of applications to nursing HEI courses in Scotland have been fluctuating in recent years: for the years 2013–2016, the number of applications were 14,520, 16,785, 16,465 and 16,400.
Numbers of applications to midwifery have declined over the same period, from 1,965 to 1,725, a reduction of 12%.

Target intakes
Each year, the Scottish Government recommends target intakes to each field of nursing practice with the aim of ensuring there are enough newly registered practitioners in each field for the future. Target intakes have been rising steadily, from 2,310 in 2012 to 3,149 in 2017. Actual intakes have also been increasing, from 2,605 in 2012 to 3,049 in 2016, an increase of 17%.
Midwifery targets have increased from 100 in 2012 to 191 in 2017; intakes have increased from 105 in 2012 to 167 in 2016, an increase of 59%.

Cohorts by SIMD quintile (source: SFC)
For the cohorts 2010 to 2015, an average 21% of Scottish-domiciled nursing students came from the 20% most deprived areas (SIMD1). The percentage in this category varied between 19% and 23% across cohorts.
For the same cohorts of midwifery students, an average of 13% of Scottish-domiciled students came from the 20% most deprived areas. The percentage varied across cohorts from 9% to 18%.

Age
Nursing students have had a relatively stable age profile in recent intakes. Currently, around 48% of students are in the 16–19 bracket and a further 28% in the 20–24 bracket.
The midwifery student age profile shows some more variation, but recent intakes have had a slightly higher proportion of students in the 16–19 bracket (around 45%).

Completion probabilities
Looking at completion rates for nursing students on three-year courses in the 2009–2013 cohorts, around 57% complete at three years, 72% at four years and 75% at five years.
Around 59% of midwifery students from these cohorts also complete at three years, increasing to 80% at four years and 84% at five years.

Gender
The percentage of male nursing students varies slightly across cohorts but is typically between 8% and 10%.
Midwifery intakes are typically 100% female. Two recent cohorts (2011 and 2014) had a single male student.

Qualifications
Nursing students have a wide range of entry qualification types. In 2016, around 35% had Higher grades/A-levels, around 30% had vocational qualifications¹ and 13% had undertaken an access course.
Midwifery students are more likely to have Higher grades/A-levels (around 60% in the 2016 cohort). Fewer midwifery students have vocational qualifications¹ and there is no formal access route into midwifery.

Nationality
Nursing students have typically been around 93% from the UK. The percentage of EEA students in the 2016 cohort was 5%.
Midwifery intakes have tended to have a slightly higher proportion of students from the UK (around 96%). The percentage of EEA students in the 2016 cohort was 4%.

1 Vocational qualifications are typically Further Education Institute qualifications. In recent cohorts, these are likely to be Scottish Credit and Qualifications Framework (SCQF) levels 6–7, for example an Access to Higher Education course (Scottish Wider Access Programme (SWAP)), a Scottish Vocational Qualification (SVQ), or a Higher National Certificate (HNC).

2.3 Access routes

Access routes were considered in relation to education generally, and nursing and midwifery specifically.

2.3.1 Access routes to education

Education up to undergraduate level comprises a wide range of types of qualifications that span the Scottish Credit and Qualifications Framework (SCQF):

Scottish Qualifications Authority (SQA)-accredited qualifications, such as the Scottish Baccalaureate in Science, are aimed at candidates in S5 and S6

Scottish Vocational Qualifications (SVQs) offer work-based opportunities

higher national qualifications such as the Higher National Certificate (HNC) and Diploma (HND) are college- and practice-based, with some courses offering articulation to relevant undergraduate programmes

Higher Education Certificate (HECert) and Diploma (HEDip) programmes are academic university courses that generally represent year 1 and 2 of undergraduate programmes, meaning articulation for the student may be smooth or, if taken within the same institution, even seamless.

The apprenticeship structure in Scotland has three levels:

Foundation apprenticeships: offered to young people in S5 and S6, the foundation apprenticeship is seen as a vocational route that can lead directly onto an industry-based modern apprenticeship. From employers' perspectives, it is about developing the talent flow. Funding is provided by Skills Development Scotland (SDS) direct to organisations such as FEIs.

Modern apprenticeships: while there are no modern apprenticeships specific to nursing and midwifery, a number are delivered across NHS boards at SCQF levels 6 and 7, including the support worker pathway and non-clinical modern apprenticeships in administration and management. They are available to employees working in the NHS and social care settings. A modern apprenticeship framework should be responsive to employer demand and be oriented around current skills needs. Funding is provided by SDS direct to training providers such as FEIs and employers.

Graduate-level apprenticeships: these are now in their second year in Scotland and are developed in partnership with HEIs and others. While the orientation is more academic than the other two apprenticeships, they remain employer-led, and are developed in response to clearly defined employer need. Graduate-level apprenticeships, like the other two forms, are completed within employment – in other words, those on the graduate apprenticeship route are in paid employment while they study. Funding is provided by SDS direct to HEIs.

All apprenticeships, and SVQs used by the social service sector, have National Occupational Standards, as developed by the Sector Skills Councils, at their heart.

The Review of the 15–24 Learner Journey programme of work is led by the Scottish Government in partnership with stakeholders and aims to review the effectiveness and efficiency of the learner journey for all 15–24-year-olds. There are two drivers for the review: learner personalisation and choice; and system efficiency. The review will consider the journey from the senior phase (S4–S6) leading to employment, including stages of further and higher education in FEIs, higher education in HEIs, vocational training and apprenticeships. The learning phase of the review did not conclude in sufficient time for the Commission to formally draw on its conclusions in making recommendations, but it is recognised that there will undoubtedly be important parallels between the work of the two reviews.

2.3.2 Access routes to nursing and midwifery (including for support workers)

The integration of health and social care poses challenges in terms of defining a common language across the new environment. The term 'healthcare support worker', for instance, is used commonly in NHS settings, but much less frequently in the context of care homes. Workforce data returns for care homes refer to just over 200 health care support workers/health care assistants/health care workers among over 50,000 care home staff records. In the care home sector, this key staff group would much more likely be referred to as 'support workers'.

The Commission found language differences such as this confusing and unhelpful. The more important consideration, however, is whether the public too finds it confusing and unhelpful. This is an issue that needs to be addressed urgently, and some of the report's recommendations seek to support efforts to make language and terms more simple and consistent across sectors, and to help the public understand what competencies and capabilities groups of workers possess.

The Commission took the view that for simplicity, and unless otherwise indicated, the term 'support worker' would be adopted as the default term throughout the report to encompass support staff with direct patient/client contact across the health and social care sector.

A range of routes by which candidates can ultimately gain access to nursing and midwifery degree-level programmes exists currently. They are nevertheless different across the professions. For instance, there is no acknowledged recognised prior learning (RPL) route for HNC students into the second year of midwifery degree programmes, as there is in nursing: while HNC students are articulating into midwifery education programmes, they are doing so in first year, not second, and are tending to do so in informal ways without guarantees of places. This differs from the situation in nursing, and is primarily driven by the requirements of the NMC nursing standards and NMC midwifery standards.

Figure 1 shows the most common current routes into pre-registration nursing programmes. A more detailed description of routes is provided in Annex 2.

The figure highlights four key groups:

people who already have a degree and apply directly to an HEI nursing programme; these applications are considered on an individual basis, and while it is conceivable that entry to a Master's programme would be granted, in practice it is very uncommon

school-leavers: those with the requisite qualifications for HEI entry can join year 1 of an HEI programme; those who do not can enter FEI programmes, depending on their qualifications, where they will acquire appropriate qualifications and work experience, or directly enter the workforce through employment

adult returners: this represents a wide range of people who may wish to change career or are not currently in employment, and who do not have the requisite qualifications; sometimes they have considerable life and work experience and wish to pursue a career in nursing through accessing an FEI programme (Scottish Wider Access Programme (SWAP) Access to Nursing, National Certificate (NC) or HNC, depending on qualifications)

people currently in employment in health and social care settings: this includes childcare workers, NHS and care home support workers, social services workers and modern apprentices; they do not have the requisite qualifications for entry to HEIs and their common route is the HNC in Care and Administrative Practice, but they can also pursue an Open University (OU) route.

Figure 1. Current widening participation routes

The college-based HNC route – with a number of places funded by the Scottish Government – articulates to year 2 (sometimes year 1) of the degree course, and other qualifications, such as the SVQ and Professional Development Awards (PDAs), may be eligible for accreditation of prior experience and learning (APEL), provided they are accredited by the SQA and mapped against the SCQF. Modern apprenticeships may provide significant funding opportunities for NHS boards in the context of the Apprenticeship Levy, though clarity is needed on the mechanisms and eligibility criteria for accessing funding.

There currently are no educational routes through which midwifery support workers can articulate directly to pre-registration midwifery education, which has a significant impact on access to the profession. No shortened courses to participation in midwifery education for qualified nurses are currently available in Scotland, although some are being planned.

Despite the establishment of integrated joint boards to commission and fund care for local populations, approaches to regulation of workers differ depending on their employer and/or their professional/work role. Many groups in the social care workforce, 69% of whom are employed by third or independent sector employers and the remainder by the public sector, are subject to statutory regulation by the Scottish Social Services Council (SSSC). The SSSC has the role of the sector skills council in Scotland and is a non-departmental public body responsible to Scottish Ministers.

All support workers employed by NHSScotland since December 2010, however, must sign up to the contractual employer-led model of regulation, which requires them to work to a set of standards and agree to abide by a code of conduct. The code and standards were reviewed in 2017 to ensure they remain fit for purpose in the context of changes to healthcare policy and delivery, including the integration of health and social care. The report from the review is currently going through governance mechanisms prior to wider discussion, but it seems likely that it will include recommendations on supporting access for support workers who wish to enter nursing or midwifery undergraduate programmes.

This issue has also been examined closely by the Commission, which found that support workers in other countries can and, in some cases, must go through an accreditation or certification process before they can practise. These processes may not be very complex, and may only equate to a period of intense induction. The Commission expects that support workers in Scotland must work towards achieving minimum standards defined by their employers prior to entering practice, but believes that integrated regulation for this group of workers needs to be explored further.

The SSSC's requirement for registration qualifications have work-based learning and adherence to the SSSC codes of practice as a central element; this includes evidence of 'observed assessed practice' and contrasts with NHS boards' educational demands for clinical support roles, creating parallel progression pathways along the largely vocational SVQ route and the more academic NC to HND route (including National Progression Awards (NPA) and PDAs). While the SVQ qualification route allows RPL in work and from previous training, ideally there should be additional recognition mechanisms in place to facilitate sideways transmissions between these two paths.

The UK Department of Health announced in December 2015 the creation of a new role of nursing associate. The role was developed by Health Education England to address the workforce planning needs of NHS England, and the Department envisages nursing associates working alongside, and bridging a perceived gap in capabilities between, health care assistants and registered nurses. The role is attained through a graduate apprenticeship scheme, with an estimated 2,000 currently in training across 11 pilot sites in England. The first tranche of trainees is due to graduate in January 2019.

All three Devolved Administrations subsequently expressed reservations about introducing a role with a proposed scope of practice almost indistinguishable from that of a registered nurse and, in the absence of a comprehensive risk analysis, resisted statutory regulation on a UK-wide basis at this time. The Devolved Administrations are awaiting evidence of the efficacy and risk presented by the new role before taking a further view on its suitability beyond NHS England.

The principal reason for the introduction of the role in England – bridging the workforce gap between health care assistants and registered nurses – does not exist in such an obvious way in Scotland. The Scottish Government nevertheless recognises that the support worker workforce requires support to develop skills and academic growth to match the requirements of band 3 and 4 roles, and which will enhance their opportunities to articulate to nursing, midwifery, allied health professional or, indeed, social care undergraduate programmes.

Other issues in this area include:

the SVQ 2 framework is workplace/competency based and requires learners to evidence the underpinning knowledge and values for each element of the SVQ, but people who hold SVQs experience lack of parity of esteem with those undertaking other routes to achieving learning

while the SSSC has some data on retention rates for the social care sector, there are limited national or regional methodologies for following-up on what happens once people have gained a qualification – where they go and what their experiences are

there is an appetite for a consistent national pathway of recognised, accredited qualifications; such a system potentially could provide vocational routes for progression and entry, both horizontally and vertically, into continuing education or employment.

2.4 Funding and support

Scotland has a wide range of funding and support mechanisms to enable people to access education and move either into careers generally or those specific to nursing and midwifery.

2.4.1 Education and careers

In relation to Further Education Access funding, the 2017/18 budget for college bursaries, childcare and discretionary funds is over £107 million. Further education students in 2017/18 will be able to receive a non-repayable bursary of up to £97.33 per week.

Scottish Funding Council (SFC) access funding initiatives include: the Disabled Students' Premium; Access to Rural Communities; Access to High Demand Professions (REACH); Schools for Higher Education Programme; Scottish Wider Access Programme (SWAP); and the Widening Access and Retention Fund. Priority 1 of the SFC outcome agreement for 2017/18 states that widening access requires 'learning that is accessible and diverse, attracting and providing more equal opportunities for people of all ages, and from all communities and backgrounds.'

The Scottish Government will receive £221 million in 2017/18 as consequentials from the UK Apprenticeship Levy, which will come to Scotland through the existing Block Grant arrangements. Currently, the levy costs NHS boards in Scotland around £30 million per year.

2.4.2 Nursing and midwifery education and careers

The Scottish Government meets the costs of pre-registration training places through the SFC, providing commissioned HEIs with funding for provision of places. In the 2016/17 academic year, the Scottish Government transferred £56,815,659 to the SFC (unit cost £7,203). A further £1,160,159 was paid to commissioned HEIs to contribute towards Honours degrees (unit cost £1,820).

The Student Awards Agency for Scotland (SAAS) assesses and pays the Nursing and Midwifery Student Bursary (NMSB), which is a non-income-assessed, non-repayable personal allowance, and other associated allowances. All eligible Scottish-domiciled nursing and midwifery students can receive a core bursary of £6,578 per annum in years 1–3; for those undertaking an Honours degree, 75% of the NMSB (£4,934) will be paid in year 4, as this element of the programme does not cover the full 52 weeks.

The bursary is distributed to students by SAAS, but is not available to those who have previously undertaken a pre-registration nursing and midwifery course and received the NMSB. The NSMB was offered to 8,915 students in 2016/17, costing £55.1 million – this was 87.9% of all financial support to students. The level of the NMSB is being kept under review going forward; significant updates have been taken forward since the beginning of the review process, with the introduction of the Discretionary Fund (see below) in 2016/17, and measures to enable targeted support for children and dependants via an increase in means-tested associated allowances.

Students in receipt of the NMSB are also entitled to apply for an Initial Expenses Allowance of £60 (paid to 3,065 students in 2016/17, costing £0.2 million, which was 0.3% of all financial support offered), and means-tested allowances are available:

Dependants Allowance – up to £2,640 for a dependant, and up to £557 for each other dependent child; it was paid to 1,125 students in 2016/17, costing £3.2 million, which was 5.1% of all financial support offered

Childcare Allowance – up to £1,216 for registered childcare costs (in 2016/17, 805, £0.9 million, 1.4%)

Single Parents Allowance – up to £1,303 (in 2016/17, 980, £1.2 million, 1.9%).

Following the first stage of the review into the effectiveness of the student support system in Scotland, these allowances were increased substantially from year 2017/18 with a view to ensuring increased support for students with additional responsibilities. Dependants Allowance is now up to £3,640; Childcare Allowance is up to £2,466; and Single Parent Allowance is up to £2,303.

The Disabled Students Allowance is available to students who have a disability or learning difficulty. It is a non-income assessed allowance to cover any extra costs or expenses related to the student's disability. In 2016/17, the allowance was offered to 375 nursing and midwifery students, costing £0.4 million (0.7% of all financial support offered).

Following the UK Government's decision to remove the health bursary and install a loans-based support package for nursing, midwifery and allied health professional students in England from academic year 2017/18, Scotland has withdrawn from the reciprocal agreement with the other three UK countries (rUK). This means that from 2017/18, students from England, Wales and Northern Ireland are no longer eligible to apply for the NMSB. These students from rUK are required to apply to their home country for fee and living-cost support. Students who were in receipt of the NMSB in 2016/17 are not affected by these changes.

Students from Scotland choosing to study in other UK countries will need to have a standard undergraduate package of a fee loan and a living-cost loan. For academic year 2017/18, the Scottish Government has agreed to fund students' tuition fees until systems can be set up in SAAS and the Student Loans Company to accommodate these loans.

A Discretionary Fund of at least £1 million has been set up to provide a 'safety net' for pre-registration nursing and midwifery degree students in most need. The fund is designed to enable them to access and/or continue in higher education and is paid in addition to any other forms of student support. The Discretionary Fund is allocated by Scottish Ministers and administered by individual HEIs.

All rUK nursing and midwifery students are entitled to apply for this fund. The maximum award to individual students is £2,500, but awards above this can be made available in extreme circumstances and with pre-approval by the Chief Nursing Officer Directorate.

To ensure nurses and midwives are fully equipped to undertake their placement experiences, funding is provided for placement expenses, uniforms, disclosure checks and health checks. Expenditure for 2016/17 was as follows: clinical placements, £1,690,000; uniforms, £197,660; disclosure checks,¹⁹ £184,000; and health checks, £941,600. The Scottish Government has agreed to fund these expenses for rUK students choosing to study in Scotland in academic year 2017/18, but not thereafter.

In partnership with NHS boards, the Scottish Government provides support to widen participation for support workers, who traditionally may not have pursued careers in nursing, to enhance their skills and experience and further their careers if they wish. Specific programmes that aim to widen participation are spearheaded by the HNC Care and Administrative Practice, which has replaced the HNC in Healthcare as the national HNC qualification for gaining entry into year 2 of nursing degree programmes. Funding allows support workers to attend an HNC course at a local FEI on a part-time basis, while still being in employment. After year 1, if the support worker chooses to undertake an HEI degree in nursing, the following options are available:

1. the support worker may resign from her or his post and become a student in an HEI, gaining access to the NMSB (£6,578 per year), with the option of joining a bank or pool to earn money possibly being available

2. the support worker may resign from her or his post but agree an honorary contract with the employer and be paid an £8,000 NHS bursary; again, the option to join a bank or pool to earn money may be available

3. the NHS board chooses to continue to pay the support worker her or his normal salary for the period of the programme and the Scottish Government provides £8,000 per student to offset costs (£4,000 backfill per year for part-time students).

In 2016/17, 189 support workers undertook this route into nursing (118 new intakes on the HNC course and 71 continuing with the nursing degree). The breakdown of funding for the course from April 2016 to March 2017 is: HNC year 1, £576,000; and HNC years 2 and 3, £546,000 (total, £1,122,000).

These opportunities are advantageous to the student and the host board. The intended outcome is that students will maintain links with their host board throughout the programme and then work for them as registered nurses on completion. Presently, the route can only be accessed by NHS support workers, but it would be beneficial to widen access to include support workers from other sectors.

Feedback from some NHS boards that do not participate in this initiative highlights that the funding package, which has increased minimally since 2003 from £7,500 to £8,000 per student, is insufficient.

Support workers also have opportunities through a Scottish Government-funded Open University (OU) programme that offers support workers in remote and rural areas the opportunity to undertake pre-registration nursing courses on a distance-learning basis.

Currently, the OU delivers a pre-registration programme for 91 nursing students in partnership with nine NHS boards and two GP practices (25 new students and 66 continuing students). One student is with Borders Council and seven work in four care homes.

Funding by the Scottish Government is £10,000 backfill per OU student, plus costs incurred for tuition fees at £402 per month per student (teaching costs, support from practice tutors (including face-to-face meetings) and module materials). Total expenditure for OU training in 2016/17 was around £898,500. OU students do not have access to the NMSB with associated allowances for child care and dependants, however, and cannot access the Discretionary Fund. Due to the geographical location of most OU students, this may cause unnecessary barriers to a nursing career: the package of financial support for these students should therefore be reviewed.

The Scottish Government has commissioned the OU to take forward a care-home pilot in which support workers from care homes have access to the same pre-registration courses. Each care-home pilot student is supported by £5,000 of Government funding. To date, seven support workers are undertaking a nursing pre-registration course.

The Scottish Government remains committed to a national Return to Practice Programme, with a minimum £450,000 investment over three years to enable former nurses and midwives to retrain and re-enter employment. Returnees will have their HEI programme fees (£1,500) fully paid. To date, around 364 former nurses and midwives have taken up the opportunity to retrain, exceeding the initial target of 75 places per year.

All newly qualified nurses and midwives continue to be guaranteed one year of employment once they complete their studies, a commitment which is not offered anywhere else in the UK.

2.5 Rapid review of international and UK approaches

A rapid review of literature focusing on experience in Australia, New Zealand, United States, Canada, rUK and Ireland was conducted on behalf of the Commission by Dr Maria Pollard and colleagues from UWS and NES.

The review confirmed that many countries are facing similar issues to Scotland, particularly around recruiting and maintaining a nursing and midwifery workforce that is educated and reflects the population. Globally, there is a shortage of nurses and midwives due to demand being greater than supply. This is further exacerbated by an ageing workforce and increasing age of the population, which add complexities to health and social care planning and delivery.

Areas that require consideration in addressing this challenge, the review suggests, include: retaining nurses and midwives in the workforce; ensuring fair reward; improving the work environment; promoting flexible working patterns; providing clarity of access routes; recruiting from a broad and diverse population (including mature workers, ethnic minority groups, men, those with work-based vocational qualifications and non-traditional learners); encouraging return to practice; and recruiting internationally.

Australia, New Zealand, United States, Canada and Ireland regulate registered nurses, who are expected to be degree-educated. Australia, Canada, Ireland and New Zealand also have clear structures for recognising prior learning.

In England, as in Scotland, registered nurses are degree-educated and registered with the NMC. Care assistants have no registration, although a care certificate has been introduced. The Shape of Caring review (Raising the Bar), published in March 2015,²⁰ recommended the development of more innovative work-based learning routes and proposed a pathway for care assistants to enter nursing.

One to One, a community case-loading service commissioned by NHS England, has recently announced funding for nurses who wish to undertake the 'Midwifery short programme' – a 78-week programme giving nurses registered in the adult field the opportunity to undertake the pre-registration midwifery programme by an accelerated route and register with the NMC as a midwife.

The rapid review concluded that the Commission should promote:

the development of clear definitions of target groups for widening access to pre-registration nursing and midwifery programmes to influence recruitment strategies

mapping of current access routes to pre-registration nursing and midwifery programmes

a review of alternative entry qualifications and admission processes of HEIs

understanding of the current provision of flexible/non-conventional programmes (such as part-time).

The full report from the rapid review is reproduced at Annex 3.

2.6 Survey among students and registered nurses

The survey was carried out on behalf of the Commission, with the report compiled by Dr Rosie Stenhouse of the University of Edinburgh.

The purpose was to enhance the Commission's understanding of key areas relating to the choice of nursing as a career, information and accessibility of access routes/pre-registration nursing degree programmes and the interface between FEIs and HEIs from the perspective of students who had experienced entry into nursing via widening access routes, or aspired to enter nursing and were currently taking courses in FEIs.

Participants were current pre-registration students (n=20, including eight OU students), registered nurses (n=2) who had entered nursing through widening access routes (two male participants comprised this very small sample), and current students in FEIs (n=150) who aspire to enter pre-registration nursing degree programmes and are undertaking either the HNC Care and Administrative Practice or Access to Nursing courses in FEIs in a range of areas, including Highland, Perthshire, Glasgow, Edinburgh and Lothian. The sample therefore represents the student journey pre-, intra- and post pre-registration education.

Data was collected from focus groups and online surveys; the focus groups were run by FEI and HEI staff, and virtual focus groups were organised by the OU using their virtual learning environment. All data were collated and themes identified across the data set for each group of participants.

While the survey was small and cannot be claimed to be representative, it nevertheless sheds light on key issues from students' perspectives that influenced the Commission's focus as its work progressed.

2.6.1 Promoting the professions' attraction

The attraction for many of a career in nursing and midwifery was based on a rational recognition of the career opportunities presented in and outside the NHS. It also reflected a desire to make a positive impact on society, rather than following a vocational 'calling'. When asked 'What attracted you to a career in nursing or midwifery?', the most prevalent reasons were personal experience, perceived educational and career opportunities, and a desire to help/make an impact on society. FEI participants focused on helping on an individual patient basis, talking about 'want[ing] to help others', while those from HEIs and registered nurses spoke of 'making a difference' on a much wider, and possibly more political, level.

Participants identified the negative image of nursing often portrayed through news media and films/TV and the impact this has on motivations to join the profession. One said:

'I think that media can show nursing in such a negative way, portraying poor wages and long working hours … [There needs to be] better advertising through social media as well as TV, targeting all ages, gender and ethnic minority.'

A need to promote the different routes into the professions to ensure wider understanding was also raised. Participants discovered these through a range of formal and informal means. There was a sense that more formal information needed to be made available: some participants identified that they had only found out about courses through word of mouth, or by being in the right place at the right time.

The diversity of roles and contexts in which nursing occurs was identified by many participants as attractive. One said:

'Nursing is a rewarding and challenging job and could provid[e] exciting and varied opportunities. It also offers routine and structure. The skills used in nursing can be used in a wide variety of formal and informal situations.'

Some felt that more needs to be done to promote this side of the profession, including the fact that nursing is not provided exclusively in the NHS. For example:

'Advertise the wide range of jobs on offer once qualified such as the forces, cruise ships or simply the different jobs that can be done within the NHS itself … I'm sure many people don't realise what is available.'

Participants spoke of the need to move beyond the concept of nursing being for young women and wanted institutions actively to promote diversity in nursing through a greater emphasis on advertising to men and older male/female students, rather than pursue exclusively its perceived heavy focus on younger school-leavers. They also talked about the need to promote a realistic view of nursing, suggesting this could be achieved through offering work-experience opportunities, advertising and ensuring that TV programmes that involve nurses are realistic. One said:

'When it comes to young students tell them what to expect on placement, tell them how much work it takes so they know where [they] stand. Show the best parts of nursing too, the thankfulness that patients show and how rewarding the profession is.'

Identified barriers to entering nursing and midwifery education and careers included:

financial, particularly for mature students who may have family responsibilities and perhaps had to give up paid employment to become students; other financial issues, such as travel costs to get to HEIs and limited employment opportunities while studying, were also considered important barriers

self-doubt and lack of confidence in negotiating HEIs' admission procedures

inappropriate home circumstances with inadequate opportunities for study (lack of good wi-fi access in rural communities, for example)

the gendered nature of nursing, with men not perceiving nursing and midwifery as 'male' professions

inconsistent information about the qualifications required, particularly around numeracy, and more generally a lack of (or inaccurate) information in schools and colleges.

Summary

Students made choices to undertake nursing and midwifery education based on opportunities offered.

Information was gained through formal and informal routes.

Prospective students had a particular focus on the diverse contexts of nursing and midwifery.

Wanting to make a difference remains a strong driver for students.

Concerns about the financial impacts of being a student were identified as a barrier.

The gendered perception of nursing and midwifery was seen as a barrier to male applicants.

2.6.2 Application processes

Responses identified either that participants felt supported when making their application and it was therefore a positive experience, or that it was a positive experience because they found the process straightforward. Those who had difficult experiences had found themselves lacking confidence, or there had been a lack of clarity/consistency in the available information. Some identified that lack of consistency in entry requirements between HEIs made the application process more challenging; additionally, some had been required to undertake numeracy tests, but found this process anxiety-provoking due to lack of clarity and communication.

Most of the current pre-registration students and registered nurses felt well supported in the application process, finding college staff helpful when completing Universities and Colleges Admissions Service (UCAS) forms; having an articulated place onto year 2 of a nursing programme was considered a positive impetus for students' work at college.

In relation to improving the ease with which people can apply to HEIs, some students found that having previous healthcare experience helped at interview stage, but were unsure about its effect overall in the application process. Despite HEIs and the NMC supporting the RPL process, no participants identified that previous experience had been taken into account in lieu of academic qualifications or enabled accelerated access into pre-registration nursing degree programmes. One respondent identified that despite having experience in caring, it was not taken into account because it was not in the same field of nursing to which the person was applying.

Summary

Generally, students who came through the FEI system felt supported in making UCAS applications.

The UCAS system was easy to follow.

The diversity of entry requirements for individual HEIs was difficult to navigate when applying.

There is a need for consistent information, particularly around numeracy.

Despite many participants citing extensive experience in healthcare settings, none identified that this was formally recognised in the admissions process.

2.6.3 The journey to higher education

A number of FEI students who had undertaken a module aimed at supporting the transition into higher education felt the design, alignment and coherence of their learner journey – their experience of moving into higher education – was well supported, as did one who had been a pupil of the Advanced Higher Hub prior to moving into nurse education. The access and HNC courses were identified as providing relevant graded content (such as Highers) as well as practice placement experience. One participant noted:

'HNC prepares you greatly by giving you underpinning knowledge, simulation sessions and placements.'

Some participants pointed to the support experienced through various schemes to bridge the gap between school/FEI and HEI. One commented:

'Some students felt having a summer placement transition module help[ed] them prepare more for the complexities of practice and they felt that the lines of communication between the colleges and the HEI were good.'

The ability to re-enter an educational context, enabling students not only to regain academic skills but also to develop other skills required to manage the learning experience, was also appreciated by some participants.

Others, however, felt less prepared and supported, particularly in relation to preparation for academic writing and other study skills (a participant noted: 'College did not teach correct essay writing skills or adequate referencing skills'), and one did not feel the HNC course provided adequate preparation for transitioning into the second year of a BSc course. One of the registered nurses suggested that increased contact with practice education facilitators during the HNC course might have better supported transition to year 2 of the degree programme, and proposed more flexible and reduced contracts with the NHS while students are undertaking their studies.

Barriers to progress once on programmes included financial pressures, difficulties accessing funding for those coming from care homes, anxieties about course content triggering cathartic reactions to events in their personal lives, self-doubt and problems meeting demands for study, work, family/friends and recreation.

Participants found themselves juggling a range of responsibilities and demands on their time. Their comments included:

'Health, family and domestic difficulties can impact at different levels throughout your time on the programme.'

'Barriers for me are mostly time management v working. I think I may have to spend more time on my assignments as I can spend a lot of time reading. I also work full time which I require to pay bills etc.'

Participants were asked how they had overcome these barriers. Their responses were scattered across a range of individual strategies, such as developing a routine and planning ahead, learning time-management skills, asking for help from tutors and managers, and increasing the amount of paid work they took on. Interestingly, the students' perceptions of means of reducing barriers did not include any actions by HEIs – all involved changes to their own approaches.

FEI students identified the high relevance of their HNC/access experiences in terms of giving them what they needed to get into nursing and midwifery courses, particularly in relation to issues such as promoting understanding on how to deal with people in different situations, recognising diversity and treating each person as an individual. These experiences also helped them to develop their academic skills and provided access to care placements. The students felt the reputation of the HNC as a stepping stone to university, and the success of previous HNC students on HEI courses, was very encouraging to them.

Summary

Students on access and HNC routes perceived these courses as being designed to gain them access to a pre-registration nursing degree programme, but competition for places on pre-registration programmes was demotivating.

The lack of clear articulation routes into year 2 of pre-registration programmes increases financial pressure on students who repeat the year they spent on the HNC.

The journey into higher education can be smooth if students are supported and prepared, particularly in relation to academic skills.

It is not, however, possible to assume that HNC or other college courses adequately prepare students for study at higher education level.

Financial and time pressures put students’ progress at risk.

2.6.4 Income sources

Most of the students received the NMSB, but some had concerns that it was too little, especially when childcare and other costs were factored in and when the fact that some mature students had had to give up paid employment to undertake their programme was considered. Comments included:

'It would be very difficult to rely on the bursary alone – I still work part time all year round to cover the costs of things.'

'Childcare – not enough funding to cover cost of hours in college and placements.'

'Mature students with children giving up jobs don't receive enough funding from colleges to cover costs.'

The need to earn money over and above the NMSB was a commonly cited pressure, compounded by difficulties fitting in paid work around the demands of an intensive degree programme. As one participant noted:

'Fulltime nature of the programme makes it difficult to e.g. over the summer to earn money to make yourself more financially prepared for the next year as you are on placement over the summer unlike other programmes.'

This pressure was not experienced by OU students, who identified that they were paid during their time as students, but they experienced difficulties getting time to study due to lack of support from colleagues.

The students were nevertheless aware that the situation in Scotland is different from the rest of the UK and that they were fortunate to receive the bursary, which provided them with a significant sum of money. Additional funding sources were also recognised and accessed; some participants had received support that included hardship money and income support.

There was a suggestion of funding disparities between those coming into nursing and midwifery education from the independent sector and those from the NHS, with one student with a care home background saying that she was made to feel 'second-rate': this student was denied access to computers at a local hospital and told she could only borrow books while on placement 'because I was from a care home'. She called for future students to be 'encouraged, not segregated, because [they] work in a care home.' OU students who were employed in care homes were aware that the money received by the homes to cover their training was lower than what was paid to the NHS, and that there were other inequalities between the sectors. One commented:

'What I am concerned about is the lack of funding available to private care homes compared to the NHS. I didn't realise that until we did the Induction Day. So I'm disappointed in that – are we not worth as much?'

Overall, students found the SAAS funding process helpful and informative and were paid on time. This reduced financial stresses, although delays were experienced by some, particularly for travel costs when on placement. Some participants from FEIs, however, reported difficulties with their funding and stressed that late payments could result in applicants having to withdraw from programmes:

'Having to chase SAAS means some drop out as [they] cannot manage the first few weeks without money.'

It is worth noting, however, that SAAS operates a guarantee date: where an application is received before 30 June, funding will be in place for the start of the course.

SAAS has further reported to the Commission that it successfully processed an increased percentage (96%) of bursaries within 21 days over the agreed targets in 2016/17.

Summary

The main source of income was the NMSB.

The NMSB does not meet participants’ living costs. Childcare costs and increased costs of mature students with dependants are particular pressures.

While the number of respondents was small, some FEI students reported experiencing later payments from SAAS than their colleagues on pre-registration nursing programmes.

2.6.5 Conclusion

The survey concluded that there needs to be a focus on:

developing positive but realistic public perceptions of nursing and midwifery, including its gendered nature

promoting diversity of nursing and midwifery roles and opportunities in careers

addressing students' financial burden, particularly for mature students and those with dependants

continuing to learn from good practice in supporting transitions between FEIs and HEIs

ensuring clear and accessible information about routes into nursing and midwifery and that there is parity of esteem with direct-entry students

supporting articulation into the second year of programmes for those coming via FEIs.

2.7 Examples of emerging approaches and pilots

Work is already underway in different parts of Scotland to put in place initiatives aimed at widening participation in nursing and midwifery education and careers. The Commission recognises this work and sees it as a solid platform from which to launch its observations and recommendations. Some examples of current initiatives are presented below.

2.7.1 Nursing access courses – OU pilot

The Scottish Government provided over £27,500 funding in October 2017 for a pilot in Grampian to widen participation in nursing education and help increase development opportunities for clinical support staff. The OU pilot is supporting 24 NHS Grampian support worker staff to undertake access courses in literacy and numeracy to enable them to achieve qualifications that may assist in applications for further study at HNC or degree level.

The numeracy qualification (SCQF level 5) for the pilot will be undertaken through the North East Scotland College (NESCOL) and the SCQF level 7 'Introduction to Health and Social Care' (K101) course with the OU in Scotland. This will enable staff to develop in their careers, irrespective of their educational and social background.

The pilot will be evaluated with the intention of widening the opportunity to support workers in the broader health and social care sector.

Clinical support staff are attracted into this route for a number of reasons, including:

the accessibility of the distance learning model, particularly for those living and working in more remote and rural areas and people with caring responsibilities

the part-time route of study offered, which is viewed as providing a better option for people who are otherwise unable to access full-time FEI- and HEI-based study routes

maintaining security of employment, particularly where family commitments or financial constraints have prevented support workers from considering the HNC Care and Administrative Practice route to nursing.

2.7.2 Primary 7 schoolboys' taster day – Robert Gordon University (RGU)

The RGU School of Nursing and Midwifery hosted a taster day for Primary 7 schoolboys from five feeder schools linked to a Fraserburgh secondary school. The initiative represents one aspect of RGU's wider gender work.

Seventeen boys attended. They spent the morning in the skills lab learning basic life support skills and getting experience of taking temperatures and blood pressures, bandaging, working with the robotic manikin and examining equipment. In the afternoon, they had a one-hour session with mental health nurses.

The day was supervised by male nurses from the School with backgrounds in adult, children and young people, and mental health nursing and who have diverse professional experiences. The boys had opportunities to ask questions when they first arrived and throughout the day. They were interested, vocal and inquisitive, asking about issues as diverse as pay, career structure, 'best and worst bits', death and negative public perceptions.

The session evaluated positively; all the boys said they enjoyed the day and had learned a lot about nursing. The head teacher and accompanying staff said they had also learned about nursing as a career and felt better equipped to advise pupils in the future.

Most interesting to RGU staff was that the head teacher said more boys had wanted to come to the day, but some parents had been reluctant to sign the consent form, perhaps highlighting the challenge nursing faces as a career choice for males in rural communities.

RGU hopes to be able to link with these schoolboys again in the future. Third-year pupils from a city secondary school are also invited to take part in the delivery of two modules in the School, and children comprise part of the interview selection panel for the children and young people's field programme.

2.7.3 Attracting men into nursing – University of Dundee

The recruitment rate for males into undergraduate nursing education at the University of Dundee currently is 8%. Attracting more males into nursing is part of the School of Nursing and Health Sciences' action plan, and staff have instituted a number of strategies aimed at increasing the proportion of males to 25% and, ultimately, achieving gender parity.

A pop-up stall was held in September 2017 in a local shopping centre involving male nursing students, lecturers, and staff from the local hospital and FEI who could advise about access programmes for applicants who lacked the necessary qualifications for HEI entry. The event was run in conjunction with a social media campaign using the hashtag #MenDoCare. The publicity from #MenDoCare led to further exposure on radio and in newspapers, and an online article on men in nursing written by one of the HEI lecturers has created much interest.

Two focus groups have been held with local male nursing students to explore facilitators and barriers to embarking on a nursing education route. Results are being analysed to inform future plans.

A male nursing student, admissions lecturer and a member of staff from the local FEI attended an event for guidance teachers in September 2017 to promote nursing as a career option for a wider group of potential school-age applicants, including males.

Staff from the Developing the Young Workforce programme have met with the HEI to discuss its campaign to encourage more male school-leavers into jobs in care. There is an enthusiasm to develop joint interventions in schools at S2/3 and revisit them in S3/4, and in exploring a primary school intervention.

A collaborative project co-led by one of the School's midwifery lecturers and involving the University of Edinburgh, UWS and RGU is currently applying for funding from NES to explore the influences and causes of underrepresentation of men in nursing in Scotland, with a view to recommending ways of influencing recruitment and planning.

2.7.4 Nursing and midwifery summer school programme – RGU and NHS Grampian

The summer school programme for senior secondary school pupils aged 16 and over is designed to provide interested young people with a realistic and comprehensive experience of nursing and midwifery education to inform their decisions about whether they represent the right career choice for them. The programme is not a hands-on work experience, but is one of a range of local initiatives designed to address pre-registration education recruitment and retention challenges.

The educational experience enables participants to:

explore what the professions are

learn and practice some core skills in the clinical skills centre

undertake some simulated practice with volunteer 'patients'

observe healthcare work in real clinical settings

interact with nurses and midwives in clinical settings

experience higher education and healthcare provision at first hand.

Applications are invited through guidance teachers in the Grampian and Moray areas. Twenty students were selected from Grampian and eight from Moray for the 2017 programme: it is very popular with pupils and is oversubscribed, so a reserve list is held.

The programme has evaluated well, both verbally and through a final day exercise. When asked 'What surprised you?' about the experience, responses from participants on the 2017 programme included:

'That I enjoyed the adult hospital and would now consider it as a career'

'The different specialties in nursing and the number of pathways you can take'

'Hearing a lot about mental health conditions and hearing the interesting stories and facts about it'

'How strongly I'm stuck on wanting to study children's nursing'

'That I decided what career path I wanted to take…finally'.

In addition to highlighting interest in clinical areas such as oncology, mental health, paediatrics, theatre and maternity, responses to a question on what they found most interesting in the experience revealed that participants appreciated:

'Seeing how the different types of nursing were similar and different'

'How much experience you can get on placement'

'The range of career paths available in nursing'.

A retrospective study of outcomes from participants at the summer schools in 2015 and 2016 found that of the 28 participants at each programme, 11 were studying nursing or midwifery at RGU.

2.7.5 The Health and Social Care Academy

The Health and Social Care Academy, the only academy of its kind in Scotland, has been running for the last four years for young people in S5 and S6. An initiative of Queen Margaret University, Edinburgh, and Edinburgh and Borders College, the overarching title is the South East Scotland Academies Partnership (SESAP). It includes young people from Edinburgh, East Lothian, West Lothian, Midlothian, Borders and Dumfries and Galloway.

Young people gain a qualification on completion of study (National 5 after one year and Higher grade after two). Students can start the National 5 in either S5 or S6, but those taking the Higher need to start in S5. The academy is an option within school curricula, with young people attending the FEI for two afternoons per week and the HEI for four sessions in the year.

The approach focuses on heightening young people's awareness of the range of career opportunities available in health and social care, including nursing, midwifery and the allied health professions. The academy enables them to acquire knowledge and relevant work experience to prepare them for study and work in health and social care. The aim is to help the young people develop transferrable skills that will make them attractive to future further and higher education providers and employers and also help to smooth the transition between school, FEI/HEI and employment. At the end of the course, graduates are in a good position to pursue a health-related course in an FEI or HEI or apply for work in health and social care.

A recent survey of academy students found they acknowledged the positive influence of the academy on their social, communication and independent learning skills. It was seen as providing a potential way to widen access to higher education and help students make more informed choices, increase their achievement and lower dropout rates in HEIs.

2.7.6 Modern apprenticeships in NHS Lothian

NHS Lothian has started to recruit modern apprenticeships into the nursing service. Twenty-two band 2 posts were advertised in two rounds across the mental health and learning disability service and Royal Hospital for Sick Children (outpatients, medical ward and paediatric intensive care unit). Thirteen posts were appointed in round 1, with interviews for remaining posts to be held in November.

The recruitment process adopted a partnership approach and involved a range of activities, including 1:1 interviews and group values exercises. It was based on a 'future potential and personal attribute and values' approach, with no education requirements set. Advertising focused on social media (Twitter, Facebook, NHS Lothian Career Pages) and partnerships with youth groups to spread the word.

The response was unprecedented for the board, with 39 applications submitted in one night. Applications closed early due to the response (150 applications in three days, with 95,000 hits on Facebook, 800 shares and 300 comments all tagging friends to the advert).

The modern apprentices started in mid-November, with education delivery starting in March/April following completion of induction and some job experience. The aim is to complete the apprenticeship in 12 months from employment.

This level of response contrasts with a steep drop-off in applications currently seen for band 5 posts in the board and suggests that modern apprenticeships may offer an important route for widening access.

2.7.7 University of the West of Scotland – MSc Midwifery

The MSc Midwifery with registration was validated in 2013, representing the only midwifery programme underpinned by master's-level education in Scotland at this time. It is an exciting and unique postgraduate pre-registration three-year midwifery programme run in conjunction with the BSc Midwifery at UWS and enables students to become highly educated midwives with the potential for management, leadership, consultancy, education and research roles.

The programme was developed in accordance with the NMC Standards for Pre-registration Midwifery Education. Students with a first degree can apply for the programme, which comprises 50% theory and 50% practice over a three-year period. All modules are core and a dissertation is undertaken in year 3.

The programme offers the opportunity for practice learning experiences across wide geographical and specialty areas, ranging from large tertiary consultant-led units to remote and rural community midwifery units. It has a dual exit qualification, with the educational level at MSc and a NMC professional qualification with entry to the register as a Registered Midwife.

The midwifery programme acknowledges the centrality of professional practice to the midwife's role and that providing care for women with both normal and complex pregnancy and childbirth can be highly challenging. It addresses current challenges facing maternity services, including vulnerable groups, sexual health, mental health, obesity and social inclusion, and seeks to produce inquisitive, innovative thinkers who understand, develop and enhance concepts of person-centred, compassionate care for childbearing women and their families.

Delivery of knowledge includes teaching at a more advanced scholarship level using a planned programme of additional tutorials and seminars to facilitate greater breadth and depth of the student's experience. This includes a wider perspective on issues such as management, leadership, clinical governance, education, research and development of new insights. The programme aims to prepare students to consider post-doctoral studies as well as project management and leadership, postgraduate teaching and learning, and specialist consultant clinical midwifery roles.

3. Observations and recommendations

This chapter sets out the Commission's observations and recommendations across three key areas:

Celebrating the impact and opportunities of nursing and midwifery education and careers

Flexible access to nursing and midwifery education and careers: making it happen

Positive commissioning.

As the rapid review of literature points out, many countries are facing similar issues to Scotland, particularly around recruiting and maintaining a nursing and midwifery workforce that is educated and reflects the population. Lessons can be learned from other countries' approaches to supporting participation in nursing and midwifery education and careers, and the impact of measures deployed. In Scotland, a myriad of policies and programmes across a wide range of sectors also affects this issue. These have been reflected in the Commission's deliberations, observations and recommendations.

3.1 Celebrating the impact and opportunities of nursing and midwifery education and careers

3.1.1 Workforce challenges

The requirement to use nursing and midwifery workload planning tools is in the process of being enshrined in forthcoming safe staffing legislation. This means it becomes even more important that interested parties retain ownership of, and involvement in, the tools' development to ensure they continue to be refreshed and remain fit for purpose as circumstances change over time.

Workforce planning must be able to meet changing models of care as set out in the Health and Social Care Delivery Plan. The National Health and Social Care Workforce Plan Part 1 forecasts that 62,400 nurses and midwives will be required in the workforce by 2021/22, equating to creating an additional 2,600 student nurse and midwife training places over the next 3–4 years. This is likely to challenge the current recruitment pool of candidates, which has seen reductions over the past three years.

The demand–supply pipeline in the Plan also identifies the need for a further 1,300 nurses and midwives working in Scotland in the period 2017–2020. A package of measures beyond the traditional three-year pre-registration programme will be required to meet this additional demand. This will include accelerating return to practice programmes, delivering enhanced access programmes for support workers, and improving recruitment, retention and completion rates, particularly in remote and rural areas.

The Plan identifies the following supply and demand challenges in NHSScotland:

higher demand for nursing and midwifery staff since 2012, with additional posts being created in NHS boards

a short-term downturn in student numbers following a previous period of reduced intake and consequent supply of newly qualified nurses and midwives, though this trend is now reversing as five successive increases in intakes begin to flow through the system

an uncertain future supply of staff due to retirement patterns and a competitive higher education and employment market, making it more difficult to attract and retain newly registered staff in Scotland (this is replicated across the UK)

current and future recruitment challenges in different areas and clinical specialties

evidence that roles need to be more responsive to demographic changes and changing service needs.

Midwifery faces particular challenges. Reports of a year-on-year increase in the retirement rate and difficulties in recruiting community midwives to work in remote and rural areas have contributed to a recent reduction in the number of qualified midwives employed in Scotland.

3.1.2 Care home sector

The task of the Commission was to look at widening participation in professional careers not only in NHSScotland, but also the independent and social care sector, where recruitment and retention of registered nurses is recognised as a significant challenge. Care homes are particularly affected, with suggestions that issues such as loosely defined roles, professional isolation and limited career progression pathways could be fuelling an unsustainable vacancy rate. The National Care Home Contract is expected to set out clearer definitions and requirements at the end of 2017, and work is underway with interested parties to collate data and create a fuller picture of the care home situation.

Current initiatives, such as the Return to Practice Programme, have had good success in the NHS, but limited reach and impact in the care home sector. Anecdotal evidence suggests that providing routes for support workers in care homes into nursing is closely linked with retaining those staff following registration. The care home sector is nevertheless competing against NHSScotland to attract support workers, placements and graduate nurses. The playing field is far from level in this regard, with most independent operators unable to match the terms and conditions on offer in the NHS.

The report of the Commission's student and registered nurse survey indicated the funding disparities between those coming from the independent sector and the NHS into nursing and midwifery education. While there may be logical reasons behind this disparity (such as the differing costs of backfilling places to allow students to study), the report states that students experience it as an indication of their perceived lower value as nurses within the care home sector. This perception draws on, and perpetuates, the dominant discourse in which care homes are undervalued in relation to NHS services, and the population care homes provide for is undervalued and perceived as a societal and healthcare burden: consequently, working in care homes is not valued as a career opportunity for nurses. Care home nursing may also be perceived to lack the professional status and progression opportunities of nursing within the NHS and the more glamorous image it enjoys (largely through portrayals in TV dramas).

Work involving the Scottish Government and stakeholders, including Scottish Care, is nevertheless underway in this area, making use of evidence from a range of sources, such as Scottish Care's Voices from the Nursing Front Line report.²¹ Although more can be done, significant progress has been made, including action to enhance the care home setting for student nurses and staff.

One of the recommendations from the Scottish Care report – to identify the core skills mix for nursing in social care – suggests that the best route to responding to the recruitment and retention challenges the care home sector faces may not simply be increasing the supply of registered nurses. The report notes that clarity is needed on the specific benefits nurses bring to care homes, and what skills are required across the care home workforce to meet demand and deliver high standards of care.

3.1.3 Young people

Attracting people, especially young people, and ensuring they have access to accurate and accessible careers advice is a key priority for sustaining the nursing and midwifery workforce now and for the future. This may include taking measures to enhance the reputation and appeal of the professions and revising commissioning mechanisms.

In an increasingly competitive labour market, the Commission asked what can be done to attract young people to nursing and midwifery education and careers? This would include higher tariff-point students who may not currently consider nursing and midwifery as their first career options. It found the following issues emerging from its reviews and consultations with stakeholders:

Information around qualifications requirements, including for those who already have degrees, should be 'uncluttered'.

There is a need to 'sell' the flexibility of nursing and midwifery careers – shifts, part-time opportunities etc. – to show how they can fit with people's lives.

Stereotypical images of nursing and midwifery, which are not always positive, need to be broken. These feed into what young people perceive they can achieve as a nurse or midwife – banishing the stereotypes will help them understand the wide positive impact they can have on people's and communities' lives.

Job prospects should be promoted across all settings, including care homes and the community, and not just acute hospitals.

Direct engagement with head teachers and careers advisers in schools is necessary to promote realistic messages around nursing and midwifery.

Proactive engagement with young people through initiatives like open days is necessary to capture their interest. The Stakeholder Group expressed interest in the idea used by the SSSC of creating ambassadors for careers in care, asking people to speak with young people about their experiences and act as role models. Role-modelling is considered a key element in creating more realistic perceptions of the professions, with a need to circulate real-life positive stories and messages on current nursing and midwifery practitioners and practice.

Public perceptions of nursing as a female profession have been highlighted as problematic and a potential disincentive to male applicants. If the anticipated workforce deficit is to be tackled, it is imperative that men are not deterred from entering the professions. Specific initiatives focusing on boys should therefore be developed. Pilot and small-scale innovations to promote recruitment and access are apparent across HEIs and regions, targeting, for example, school-leavers and male applicants (see Section 2.7 for examples). The learning from these needs to be analysed to provide an evidence base of what works best. As the report of the Commission's student and registered nurse survey suggests, there is a need to challenge the concept of 'care' in relation to nursing and midwifery and understand better why men appear less interested than women in pursuing careers in the caring professions.

There is a need to understand generational drivers – the issues that drive the interest and enthusiasm of successive generations differ, these need to be understood and maximised.

Data from the Commission's student and registered nurse survey points to the need to improve provision of information across the student journey to ensure it is clear and consistent. This lack of clarity appears particularly problematic when participants are applying to HEIs. Equally, there is a need to ensure that information about the various routes through nursing and midwifery education is widely available.

Funding information should be simplified and made more readily available.

Clear pathways and access routes, including financial support and opportunities for progression, are required.

3.1.4 Marketing nursing and midwifery

Central to making progress on the issues set out above is the idea of marketing nursing and midwifery to the public, especially young people and higher tariff-point students, through a national campaign with different emphases for different audiences, such as men and young school-leavers.

Data from the Commission's student and registered nurse survey highlights a strong sense that participants had made career choices to enter nursing based on the opportunities offered by the diverse nature of the profession. This should lead to a reconsideration of how the nursing profession promotes itself to potential recruits. Participants suggested that nursing and midwifery could be made more attractive career options by promoting positive and realistic images of the professions' diversity (people can work in many different settings and in different parts of the world), the conditions under which nurses and midwives work, how they are valued and the attractiveness of these careers to men.

Scotland is not starting from zero on this: a national marketing campaign, Extraordinary Everyday, was developed some years ago but not utilised to best effect. An opportunity now arises to revisit Extraordinary Everyday and develop a new fit-for-purpose campaign to present a positive and realistic image of nursing and midwifery to the public.

There is also scope for nursing and midwifery to connect with and learn from current initiatives aimed at raising public awareness of careers in areas such as early years, child care, social care and teaching. Such initiatives have interests in similar audiences as nursing and midwifery, such as school-leavers and men.

3.1.5 Summary Observations

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.

Recommendations

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 NHSScotland

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.

3.2 Flexible access to nursing and midwifery education and careers: making it happen

As part of the overall undergraduate offer in Scotland, nursing and midwifery are doing fairly well in developing measures to widen participation in areas such as socioeconomic background. Indeed, nursing and midwifery are crucial contributors to supporting HEIs to meet their widening participation targets. Wide differences nevertheless exist across fields of nursing practice and midwifery, and across HEIs. Discrepancies across the higher education landscape generally need to be better understood. To this end, FEIs, HEIs, SQA, SSSC and NES should get together to look at the issue critically and propose some solutions.

This section considers flexible access from a number of perspectives. First, it considers current access routes in the round, before looking at the situation for particular groups (those on apprenticeships, support workers, those on HNC and HND routes, graduates and adult returners, and those wishing to change field of practice). It then turns to articulation routes and flexible and part-time routes, before considering placements.

3.2.1 Current access routes

A range of access routes and support measures is in place within a well-established SQA framework. Issues relating to educational provision have nevertheless emerged, including:

the range of access routes available has grown 'organically' without an overarching strategic direction; some routes have therefore waxed and waned, and others have not grown since inception

current central commissioning processes and targets do not focus specifically on setting out expectations of total numbers of students on widening-access routes or the growth that would be expected in this area

the current pre-registration performance-monitoring process led by NES provides some data on student numbers for individual HEIs and nationally, but does not present an analysis of the performance of access routes

current SFC HEI outcome agreements provide a clear direction for HEIs on expectations and targets for participation, but they are not specific to nursing and midwifery courses; indeed, at times they can be unrealistic within the current student nurse/midwife profile (setting a target of 25% male students in training, for example)

FEIs have outcome agreements that could be used to provide a more consistent approach with HEIs and employers to strengthen partnerships and respond to, and provide, local and regional solutions

concerns have been raised by stakeholders that the reduction from six to three in the number of HEIs offering midwifery programmes in Scotland may be hindering access for potential students, particularly in the Highlands and remote and rural areas.

Various entry criteria exist across HEIs, leading to potential lack of clarity and disappointment for undergraduate applicants. These are compounded by HEIs adopting different terms for what are essentially the same things – some HEIs, for example, refer to entry requirements as 'minimal', while others speak of 'typical' and yet others 'standard'. Universities Scotland is taking forward work that will help to address issues around diversity of entry requirements and other areas by promoting the adoption of common language across HEIs. Its Working to Widen Access report states:

'[There is a] need for greater clarity, consistency and transparency in the language that universities use when it comes to widening access. The terms used for good initiatives like contextualised admissions and articulation are not user-friendly and not always used by universities in the same way. We will change this by developing a common language used by universities.' ²²

Entry requirements will continue to differ, but the language will become more consistent, which will help prospective students. Improved communication of HEI entry criteria with FEIs will improve the clarity of entry criteria for all prospective students and facilitate their choice of which HEI to attend. It is important, however, that work should commence now to ensure consistent entry criteria across HEIs to provide clarity for all prospective nursing and midwifery students and enhance their ability to choose the right HEI for them: this point has also been emphasised in the Universities Scotland report.

The current system is working reasonably well for those on 'traditional' access routes, but appears to work less well for those with 'non-traditional' backgrounds or who do not readily meet formal requirements. The path to nursing is less clear for these students and is open to regional variation.

Wide-ranging and firmly established packages of support, including financial support, are already in place for institutions and individual learners, but remote and rural support to improve recruitment and retention is seen as an area requiring attention. The Commission is aware of incentive schemes available to other professions to promote the attractiveness of remote and rural settings and believes such schemes should also be considered for nursing and midwifery.

The current system is also less readily applicable to the social care context – relevant qualifications are not recognised with equivalency across health and social care settings. It is not clear currently how prior learning and employment experience in social care are recognised and valued in nursing and midwifery education.

The current inflexibility of the midwifery undergraduate programme needs to be challenged, with a new approach that recognises the flexibility of other pathways being introduced. This reflects the specific challenges facing Scotland and should not be dependent on a UK timeframe for the revision of NMC standards. In particular, restrictions to midwifery support staff from articulating into midwifery undergraduate programmes need to be removed.

The new NMC standards for nursing and midwifery education are likely to impact on widening participation through requirements for the range of skills necessary at the end of training and at agreed transition points – this is particularly relevant to HNC and other APEL routes, including shortened courses for graduates. Changes to requirements for practice assessment and supervision (previously mentorship) may affect the capacity and capability of non-NHS training providers, such as care homes, as well as NHS boards.

3.2.2 Apprenticeships

A number of modern apprenticeship frameworks include skills development that is directly related to health and social care practice, but there are indications that the existing support worker framework is underutilised within the service. In those areas and sectors in which they are being progressed, however, useful learning about demand and the potential of modern apprenticeships to lead to progressive career development in health and social care is emerging (see, for instance, the example from NHS Lothian in Section 2.7.6).

Additional clarity about onward access to further qualifications and study, including access to pre-registration nursing and midwifery programmes, from apprenticeships is needed. Common language and a wider understanding (particularly among HEIs) of the existing frameworks might assist in promoting the value of apprenticeships as a suitable prerequisite for nursing and midwifery undergraduate education.

The aim in Scotland is to increase the number of modern apprenticeships to around 30,000 new starts yearly until 2020 and also increase their quality and value within the wider economy, with a greater focus on science, technology, engineering and mathematics (STEM) activity.

A work-based learning approach is seen to be at the heart of this aspiration, with employers driving what the apprenticeships should look like.

NHS boards, as the country's largest suite of employers, have an opportunity through the Scottish Apprenticeship Advisory Board to define what kinds of apprenticeship should be developed to meet current and future employment needs, and how this should be supported through policy and funding. Equally, HEIs have an opportunity to influence content to enable widened access to HEI-level programmes for those with apprenticeship qualifications.

The Commission considers that the graduate apprentice route offers potential benefits for nursing and midwifery that currently are not being fully realised. It would appear to be a particularly apposite model for students in remote and rural settings, who can remain embedded in local practice settings while attending an HEI (either physically or virtually, or a combination) for around a day a week.

3.2.3 Support workers

Greater data is required on the numbers of band 2, 3 and 4 support workers in NHSScotland and care homes and the roles they perform to support the development of a clear and flexible career framework with articulation routes into nursing and midwifery.

Different education pathways for support workers in NHS boards may result in a lack of consistent opportunities to progress to nursing programmes. NHS boards and other employers in the health and care sector should consider opening access to SWAP routes to nursing for support workers, in addition to the current HNC route. This would widen access to nursing programmes to a larger demographic of workers with no formal education qualifications.

Results from the Scottish Government-funded OU pilot in Grampian for widening participation in nursing education to help increase development opportunities for support workers (see Section 2.7.1) should be carefully analysed and, if found to be productive, the approach should be considered for extension across Scotland, ensuring that support workers across the health and social care sector are included.

The Commission is eager to reflect on a wider issue related to healthcare professionals in general and support workers in particular which, while perhaps not seeming to be linked directly to widening participation, nevertheless is an issue of great significance.

The Commission observed that the regulatory system for registered healthcare professionals, which has for the most part evolved piecemeal over a long period, is complex, cumbersome and expensive. In accepting that the overarching role of professional regulation is to protect the public through a proportionate and transparent approach, the UK-wide consultation Promoting Professionalism, Reforming Regulation,²³ currently being run on behalf of the four administrations by the Department of Health in England to seek views on broad reform of regulation, is welcome.

The Commission also observed that support workers in health and social care in Scotland are subject to respective parallel regulatory regimes established under different Scotland-specific legislation. This arrangement presents barriers to workforce flexibility under integration and, specifically, to the ease with which support workers in social care can articulate to pre-registration nursing programmes. Career pathways between health and social care are being considered within Part 2 of the National Health and Social Care Workforce Plan, to be published in December 2017.

3.2.4 Higher National Certificate and Diploma courses

A two-tier situation exists currently, with HNC study enabling students to articulate into the nursing programmes of some HEIs, but not all.

Among HEIs that offer articulation for HNC students, lack of clarity exists, with some students articulating into year 1 (level 7) while others enter at year 2 (level 8) of nursing programmes. For those articulating into year 1, the journey to becoming a registered nurse is long; this makes little sense when service and financial pressures dictate that registered nurses should be prepared as quickly as is feasible, consistent with meeting requirements for registration. It also increases the financial pressure on students, who find themselves having to subsist for longer on incomes largely determined by the NMSB.

Consideration should be given to facilitating year 2 entrance for all successful HNC students: this could result in improved retention and an increase of graduates into the workforce annually. Examples of good practice in which students are able to articulate into nursing degree programmes exist and provide learning opportunities for others. Outwith nursing, good practice in supporting transitions can be found across UK HEIs and in the international literature.

It is recognised that the report of the Commission's student and registered nurse survey commented that while undertaking a course in an FEI might prepare students for entering an HEI, care may need to be taken to ensure that students develop their academic skills and feel confident they are at a level commensurate with HEI study. Additional work may be required to prepare students for the transition into year 2 of a degree programme, perhaps not so much in terms of knowledge content, but in relation to learning and teaching methods and expectations.

The Commission debated articulation practices around the HND qualification. The HND should enable qualification holders to articulate into level 9 (year 3) of nursing courses, but practice across HEIs currently is either inconsistent, or non-existent. This issue, however, is not one on which the Commission can comment further until the revised NMC standards for education are published. It is anticipated that the position of the HND and its link into nursing programmes will be articulated through the standards review process.

Currently, there is no articulation into year 3 of nursing programmes, as the NMC limits recognition of prior learning to 50% of a programme's content. This means that for some students who complete HNC and HND programmes before articulating into the nursing course, it can take five years to register as a nurse.

HEIs have ring-fenced places for students from FEIs in their own regions – it is therefore unlikely that, for example, an HEI in Edinburgh will provide a place for an FEI student based in Aberdeen. This is something that could be addressed through commissioning processes, with HEIs being required to provide a proportion of places to students articulating from other regions of the country.

3.2.5 Graduates and adult returners

While much of the focus inevitably falls on enhancing access for students articulating through further education and support worker routes, sight must not be lost of the need to enable access to existing graduates who wish to articulate into nursing and midwifery programmes. In addition, HEIs should consider more flexible routes to support adult returners with challenging personal/family commitments. This would lead to increased applications for nursing and midwifery programmes and widen access to a broader demographic.

3.2.6 Changing fields of practice

Students should be given the opportunity to change fields of practice through conversion courses. Demand for this seems to be increasing, both from students who are perhaps unsure of which field of practice to pursue, and those who want to work in a defined field but would like to gain registration in another field beforehand. Pre-registration courses expose students to a wide range of clinical experiences, and enthusiasm for pursuing an alternative field of practice should not be blunted by lack of opportunity.

At present, registered nurses on the adult part of the register in England can retrain as a midwife in less than two years, but while this opportunity used to be available in Scotland, it no longer is so. Such courses should therefore be considered for existing registered nurses wishing to change their career direction by pursuing a different field of nursing, or midwifery. This may be facilitated through articulation into year 2 of field programmes: the new NMC standards may make conversion easier.

3.2.7 Articulation routes

The current cluttered matrix of articulation routes and pathways creates confusion and lack of commonality in programme content and construction. There is a need to sense-check and reach consensus on existing routes into nursing pre-registration programmes.²⁴

Not all HEIs have 'access courses', and articulation is not an accepted route across all HEIs. Other HEIs already have a very wide access gate, and may struggle if it was to be extended even further (attrition rates are higher for widening access students, with retention rates about 10% less than for other students). These, combined with the two-tier situation highlighted previously in which HNC study enables students to articulate into the nursing programmes of some, but not all, HEIs, provide support for a common articulation framework across the country.

The report of the Commission's student and registered nurse survey suggests that the perception of high competition for places on pre-registration nursing degree courses, and the demotivating impact of this, requires further investigation. Why, the report asks, do students on HNC and access courses perceive that they have less chance of success in situations where there is competition for places? How do HEI admissions policies reduce the opportunities for successful application to nursing programmes? Any investigation should consider these perceptions and policies to identify where to focus interventions.

The situation in relation to access and articulation clearly is very cumbersome, and the task of creating a common articulation framework would be complex: it would require the creation of a dedicated working group representing relevant stakeholders, and would take time. The Commission believes, however, that this should be the goal.

A national single framework for articulation routes that allows, for example, a worker in Orkney to articulate smoothly with a programme in Dumfries, would help service providers and FEIs/HEIs to ensure that programmes are fit for purpose and meet local needs within the national framework. The reported misunderstandings about language that are hampering conversations between service providers and FEIs/HEIs would also be helped by a simplified framework that uses a common language.

3.2.8 Flexible and part-time routes

Scotland currently has little shortened-course provision, very few conversion courses and a paucity of flexible and part-time routes to registration. This must be acting as a disincentive to some potential students who, for reasons of personal circumstances, geographical location or economic status, find the option of a full-time HEI degree course prohibitive.

The Commission's aim is to widen participation in further and higher education courses related to nursing and midwifery for students from all parts of Scotland, which calls for better and more flexible course provision and delivery. It bases its observations and recommendations on evidence supplied directly to the Commission, and from the literature and international approaches.

The rapid review of UK and international literature confirmed that mature students, for example, have the benefit of life experience, emotional maturity and intrinsic motivation and have the potential to form a sustainable workforce, as they tend to work locally and stay in the profession longer. Many mature students have life commitments, but are expected to fit into existing programmes that have limited flexibility. Part-time programmes may be an option for potential students who cannot commit to a full-time conventional programme, the review suggests, citing research reported in 2014 on the impact of the OU's pre-registration programme on students' employability, career progression and contribution to the UK workforce. Employers found the part-time programme provided the flexibility to grow their own workforce, and students reported that it provided an opportunity to achieve their ambitions that could not have been accessed through conventional routes due to personal circumstances.

Part-time and flexible provision has nevertheless largely been absent from nursing and midwifery programmes. With the exception of the OU, current provision amounts to less than 1% of the total student population. The removal of the NMC requirement for completion of training within set timescales in 2016, long seen as a barrier to part-time provision, now offers an opportunity to better explore flexible and part-time routes. The fact that programmes will have to be re-written to reflect the new NMC standards suggests that now would be a good time to consider introducing part-time and flexible options, although the issue of placements within this landscape will be challenging.

Stakeholders urged that a wide definition of 'part-time' be used in these considerations. Some may assume that part-time means having licence to dip in and out of lecture programmes throughout the week and transition to registration over six or seven years: this is much too restrictive a definition, and needs to be augmented by the full range of flexible, distance and online learning provision options currently available to students of other subjects.

3.2.9 Placements

In relation to placements, more should be located in care homes, but the current placement model for students needs to be amended to gain maximum benefits for students from the care home experience, alongside the promotion of more realistic perceptions of care home nursing to ensure it attains parity of esteem with practice in all other sectors.

This reflects the Commission's belief that care homes and care in the community settings provide the broad range of clinical complexity students need to experience on placements and should be considered as such. These settings should comprise an integral part of, and not be considered an add-on to, placements for students.

3.2.10 SUMMARY OBSERVATIONS

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 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 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 and careers. The Commission 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 vs graduateness',²⁵ 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 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.

Recommendations

3. A working group should be commissioned to develop a common articulation framework for nursing and midwifery careers in Scotland, building on the existing 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 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 SWAP routes to nursing for support workers, in addition to the current HNC route.

6. Consideration should be given to extending the approach set out in the Scottish Government-funded 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 HEI 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.

3.3 Positive commissioning

Commissioning and funding were key considerations for the Commission and the stakeholders with whom it engaged. Making concrete recommendations in this area is fraught with difficulty, as the Commission has no locus over the level of funding provided to secure student places in FEIs and HEIs and support students through their programmes. What follows, then, reflects key elements of the reflections and ideas that emerged in this area through the Commission's processes, with some observations and recommendations for action that might support progress in this area.

3.3.1 Funding access routes

As was established in Section 2.4.2, all nursing and midwifery pre-registration student places and the bursaries, fees and other allowances that support students are commissioned and provided by the Scottish Government. The Government does not, however, directly commission specific access routes: outputs are defined only in the numbers of new registered nurses and midwives required in any given year across the fields of nursing practice and midwifery, with specific numbers commissioned from each HEI.

There is a strong case for the Government to embed outcomes as part of the commissioning process to actively support and incentivise widening participation. This could also provide an effective means of promoting greater diversity in student intakes. The Outcomes Agreement procedure with individual HEIs would offer a mechanism for progressing this measure. Attention would need to be paid, however, to the impact of widening participation on completion rates in some HEIs (as was stated in Section 3.2.7, retention rates are about 10% less for widening access students).

There is widespread support for commissioning numbers of students over longer planning timescales, as per the three-year cycle currently in operation. This allows HEIs to work together in planning recruitment pathways and may also enable modelling for the potential repercussions of Brexit from March 2019 to be factored in early.

The need for additional and more targeted support toward particular widening- participation targets, such as potential students in remote and rural settings, has been strongly expressed to the Commission, particularly in light of learning from the national recruitment model for learning disability nursing programmes in Scotland.

3.3.2 Student access to funds

The NMSB review began in 2016, aiming to ensure that the student support package for nursing and midwifery students was fit for purpose, fair, affordable, sustainable, transparent, accessible and adjustable. The Review Group recommended that from academic year 2017/18, the level of allowances to support students most in need should be increased, and this recommendation was accepted and implemented. The Group made some further recommendations for changes to the support package from 2018/19, but it was decided to defer consideration of them until the Commission had reported.

Data from the Commission's student and registered nurse survey highlights the financial burden experienced by students who find that the bursary is insufficient to live on, particularly for those with children or other dependants. This financial pressure leads to student nurses experiencing the stress of holding down part-time jobs to support themselves through their programmes, placing additional pressure on them during placement times. These findings are consistent with those of the 2016 review of the NMSB. There is a need to examine possible alternative funding models that will enable students to meet their basic living costs.

Options to allow students to access additional funding beyond the NMSB therefore need to be reviewed. The bursary, while substantial, barely covers most HEIs' accommodation costs, which leaves little for students' other needs. Calls have been made to the Commission to support the idea of a minimum income guarantee for nursing and midwifery students. This would potentially avoid the situation of students reducing their study time by having to work at additional jobs to enhance their income. As the Commission's report was going to press, the review into the effectiveness of the student support system in Scotland recommended to the Scottish Government that students in higher and further education should receive a guaranteed minimum income of £8,100 a year, a figure calculated from the pay of workers receiving the Scottish Government's living wage of £8.45 per hour.

Questions have also been raised to the Commission about student nurses and midwives being disqualified from accessing loans through the Student Loans Company. Students see this as being discriminatory: it does not apply to any other students in Scotland. They recognise that the loans would need to be reimbursed from their salaries over time, but many would prefer this option to seeking loans from commercial outlets, which are more expensive.

3.3.3 Support for support workers

The situation described in Section 3.2.3 regarding support workers' access to HNC courses needs to be further clarified. Observations from practice suggest a varied picture in how employment support is being offered, leading to confusion and disillusionment among support workers who aspire to careers in nursing or midwifery and for services. Absolute clarity on employers' offers of contract on qualifying/registering would encourage experienced support workers to take up their studies by removing a serious risk factor from the equation.

Stakeholders have suggested that existing funding routes for HNC students should be reviewed to ensure they remain fit for purpose in the wider health and social care landscape, considering particularly the needs of support workers in care home settings. Concerns were expressed that the level of funding, which may be insufficient for organisations to put backfill arrangements in place (currently set at £8,000 per annum), acts as a disincentive for organisations to progress HNC opportunities.

OU students do not have access to the NMSB with associated allowances for childcare and dependants, and cannot access the Discretionary Fund. Due to the geographical location of most OU students, this may cause unnecessary barriers to a nursing career: the package of financial support for these students should therefore be reviewed.

3.3.4 Summary Observations

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.

Recommendations

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 NMSB, 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 in 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.

Conclusion

The Impact for Access project funded by the SFC set the following outcomes for nursing and midwifery:

increase the retention and completion rates in nursing and midwifery

improve the gender balance across all fields of nursing

increase regional collaboration between universities across all fields of nursing and midwifery provision

increase collaboration with Scotland's Colleges to strengthen access and articulation into pre-registration programmes.

The observations and recommendations delivered in this final report of the Commission will, we believe, enable progress to be made across all of these areas.

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.

This final report summarises the Commission's observations and recommendations, based on the relevant information and evidence regarding access to nursing and midwifery education and careers it has gathered. It reflects the views of a wide range of stakeholders and identifies key areas in which action is required to widen participation in nursing and midwifery education and careers now and in the future.

Action in this area requires partnership-working to produce national, flexible and transferable education solutions. 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 importance of widening participation in education and careers is not unique to nursing and midwifery, and some transferable issues and learning exists across healthcare and other professions. It will remain important to channel and maximise impacts and learning from approaches to widening participation in education and employment generally as we progress.

There are many areas relevant to widening participation in nursing and midwifery education and careers that for logistical and practical reasons, the Commission has been unable to address in detail. These include issues as diverse as the impact of Brexit, specific measures to support people with disabilities and those from ethnic minority communities, the ongoing fitness for purpose of some existing routes, and the availability of broadband access throughout Scotland (which presents a barrier to those wishing to study by distance or online learning means). Each of these highly relevant issues, and others, will undoubtedly be addressed through wider mechanisms in place now and in the future that focus on developing social, economic, employment, health and education policy and practice in Scotland. Implementation of the Commission's recommendations will also have a positive impact on these issues moving forward.

In addition, some of the areas in which we have been able to focus attention and suggest actions – such as the gendered nature of nursing and midwifery and the status and future contribution of the care home sector to nursing and midwifery education and careers – demand much greater specific focus and tailored actions. And the question of how nursing develops as a graduate profession from the moment of students' first interaction with their HEI programmes throughout their postgraduate careers and research activity – the concept of graduateness – needs to be teased out further.

The Commission has nevertheless been able to process a great deal of information and evidence over a relatively short period of time. This has enabled it to produce what we believe are observations and recommendations that will have an impact in this area. They are set within a positive narrative of achievement in Scotland. Scotland has led the way in many areas, such as developing the nursing and midwifery workload and workforce planning tools and putting in place measures to help support workers, and these initiatives have been replicated in the UK and elsewhere. The appointment of the Commission is in itself a positive development, signalling a willingness to identify and act on perceived challenges with confidence and transparency.

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.

Annex 1. Stakeholder Group members and secretariat

Name | Organisation/representing
Paul Martin (Chair) | University of the West of Scotland
Catherine Thomas | Skills Development Scotland
Sybil Lang | College Development Network
Eleanor Brown | Perth College
Anne Marie Dempsey | Edinburgh College
Becca Gatherum | Scottish Care
Jane Cantrell | NHS Education for Scotland
Susan Key | NHS Education for Scotland
Ellen Hudson | Royal College of Nursing Scotland
Mari Brannigan | Representing integrated joint board chief officers
Maria Docherty | Representing integrated joint board chief officers
Janet Corcoran | NHS Lothian
Hazel Borland | NHS Ayrshire and Arran Representing the Scottish Executive Nurse Directors (SEND)
Candy Munro | Colleges Development Network
Maria Pollard | University of the West of Scotland
Alan McLachlan | Universities Scotland
Katrina Castle | Universities Scotland
Nick McAlister | NHS Lothian
Michael Davidson | Open University
Joyce Cavaye | Open University
Lauren McNamara | Student Awards Agency for Scotland
Lorna Caldwell | Student Awards Agency for Scotland
Mary Ross-Davie | Royal College of Midwives Scotland
Louise Gaddi | Scottish Qualifications Authority
Ros Shaw | Royal College of Nursing Scotland (union representative)
Gavin Fergie | UNITE the Union
Ian Murray | Robert Gordon University/Council of Deans of Health Scotland
Lynn Kilbride | University of Dundee/Council of Deans of Health Scotland
Andrew Bowman | Nursing student
Kirsty Maison | Midwifery student
Rachel McInnes | Midwifery student
Ann McSorley | Scottish Social Services Council
Duncan Condie | Scottish Funding Council
Hugh Masters | Scottish Government
Janet McVea | Scottish Government
Stephen Lea-Ross | Scottish Government
Donna O’Boyle | Scottish Government
Nigel Robinson | Scottish Government
Ann Pullar | Scottish Government

Annex 2. Current further education qualifications offered and routes to progression and articulation to nursing programmes in Scotland

SCQF levels | Average SCQF points | Named programme/course | Target group | Study routes | Progression and articulation routes
5 | N/A | National 5 Health and Social Care | School-leavers Adult returnees Employed staff | Full-time and part-time | SWAP Access to Nursing (subject to eligibility) College designed access to nursing courses NC Health and Social Care Higher Care Employment
5 | Varies | National Progression Award | School-leavers Adult returnees Employed staff | Full-time and part-time | SWAP Access to Nursing (subject to eligibility) College designed access to nursing courses NC Health and Social Care Higher Care Employment
6 | 108 | Access to Nursing | School-leavers Adult returnees | Full-time | HEI nursing degree (year 1)
6 | 108 | SWAP Access to Nursing | Adult returnees | Full-time | HEI nursing degree (year 1)
6 | 72 | National Certificate Health and Social Care | School-leavers Adult returnees | Full-time and part-time | HEI nursing degree (year 1)
6 | 24 | Higher Care | School-leavers Adult returnees | Full-time as part of school/FEI programme of study | HEI nursing degree (year 1)
6 | Varies | PDAs | Adult returnees | Part-time | Employment Further and higher education courses
6 | Varies: minimum 51, maximum 58 | Foundation Apprenticeship | Senior phase school/FEI partnership programme | Part-time | HEI nursing degree (year 1) Further and higher education courses Employment
6 | Varies | SVQ2 Social Services and Modern Apprenticeship | School-leavers Adult returnees Employed staff | Part-time | Further and higher education courses Employment
7 | 32 | Advanced Higher | School pupils School-leavers | Part-time | HEI nursing degree (year 1)
7 | 96–120 | HNC Care and Administrative Practice | School-leavers Adult returnees Employed staff | Full-time and part-time | HEI nursing degree (year 1 and 2) (year 2 places subject to availability of HEI numbers)
7 | Varies: minimum 69, maximum 84 | SVQ 3 Social Services and Modern Apprenticeship | Adult returnees Employed staff | Full-time and part-time | Further and higher education courses Employment
7 | 104 | Scottish Baccalaureates | School pupils School-leavers | Full-time | Further and higher education courses HEI nursing degree (year 1)
8 | 240 | HND Care and Administrative Practice | School-leavers Adult returnees Employed staff | Full-time and part-time | HEI nursing degree (year 1 and 2) (year 2 places subject to availability of HEI numbers)

Annex 3. Rapid review of the literature – policy and practice

Dr Maria Pollard and Margo Stewart, University of the West of Scotland, and Alan Gillies, NHS Education for Scotland.

Globally there is a shortage of nurses and midwives due to demand being greater than supply. This is further exacerbated by an ageing workforce and increasing age of the population, which brings increasing complexities to health and social care.²⁶ The challenge globally lies with recruiting and maintaining an appropriate workforce that reflects the population and educating that workforce. Areas that require consideration to address this challenge include:

retention – keeping those currently in employment (professional development, autonomy)

fair reward, improving the work environment, flexible working patterns

clarity of access routes

recruitment from a broad and diverse population, for example mature workers, ethnic minority groups, men, those with work-based experience vocational qualifications, non-traditional learners

return to practice

international recruitment.

Education mobility is central to quickly, efficiently and effectively educating people to become registered nurses and midwives. Birkhead et al.²⁷ describe education mobility as seamless academic progression by giving credit for previous education or experience without having to repeat content or engage in similar learning. This means developing a robust model where there is coordination of programme content between education institutions (schools, FEIs and HEIs). The benefits of education mobility include:

lifelong learning and personal achievement

growth of a registered workforce more quickly

increased diversity of the workforce.

Cavendish²⁸ highlighted the need to: 'develop innovative funding routes for non-traditional staff to progress' and recommended the development of a 'robust career development framework for health and social care support staff, linked to the simplified job roles and core competences'.

A rapid desktop review was undertaken to identify other countries (rUK and international) approaches to widening access to nursing and midwifery and whilst it contains a selection of material gathered from a search of the evidence base, it is not intended to be comprehensive. International evidence focused on countries such as Australia, New Zealand, United States, and Ireland. From an rUK perspective, the evidence considered was mostly from England.

Search strategy

This summary is based on a rapid review of policy documents and websites in selected English-speaking countries on nursing roles and pathways to nursing careers. Searches of Google were conducted on the following key terms: accreditation of prior experiential learning; accreditation of prior learning; recognition of prior learning; widening access; routes of entry; flexible modes of entry; pathways; AND nursing/midwifery. In order to focus the results to countries of interest, country-specific Google sites were used (https://www.google.com.au/, https://www.google.ca, etc). In addition, the websites of the nursing regulatory bodies in each country were checked individually for relevant policy documents.

United States

Nurse roles and qualifications

Licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) provide basic nursing care, under the direction of registered nurses and doctors. They must complete a state-approved educational programme (certificate or diploma), which typically takes about one year to complete. They must also be licensed through passing the relevant National Council Licensure Examination (NCLEX-PN).²⁹ Registered nurses (RNs) usually take one of three education paths:³⁰

a Bachelor of Science degree in nursing (BSN)

an associate's degree in nursing (ADN)

a diploma from an approved nursing programme.

Registered nurses also must be licensed, through passing the NCLEX-RN.

The Bachelor of Science in Nursing (BS/BSN) is a four-year degree offered at colleges and universities. The Associate Degree in Nursing (ADN) is a two-year degree offered by community colleges and hospital-based schools of nursing that prepares individuals for a defined technical scope of practice. The Diploma in Nursing is available through hospital-based schools of nursing. It was once the most common route.³¹ Licensed graduates of any of the three types of education programmes qualify for entry-level positions as a staff nurse, but some employers may request a bachelor's degree.³²

Pathways

An LPN may complete a LPN to RN education programme.³³ Those with diplomas or associate degrees may complete an RN to BSN programme or an RN to MSN programme. There are accelerated programmes for those who wish to enter the nursing profession and already hold a bachelor's degree in another field.³⁴

The American Association of Colleges of Nursing published a position statement on 'Diversity, inclusion and equity in academic nursing' in March 2017. It stated that:³⁵

'…realizing the benefits of diversity in the profession of nursing depends in part on expansion of the traditional pool of nursing school applicants … The measures of an applicant's readiness for nursing education and preparedness for practice should extend beyond reliance on specific quantitative data … Factors such as … ability to gain entrée into underserved communities, other transferable skills and abilities, and prior life experiences of individuals, may be relevant.'

One approach is the use of 'holistic review':³⁶

'… a university admissions strategy that assesses an applicant's unique experiences alongside traditional measures of academic achievement such as grades and test scores. It is designed to help universities consider a broad range of factors reflecting the applicant's academic readiness, contribution to the incoming class, and potential for success both in school and later as a professional.'

According to a 2014 survey, only 47% of nursing schools in the US were using holistic review in their admissions, compared to 93% of dental schools and 91% of medical schools.³⁷

Training programmes have been developed to help dental and medical schools develop mission-based holistic admissions processes, but similar training does not yet exist for schools of nursing. AACN and Urban Universities for HEALTH created a pilot workshop for nursing deans to address this need for education and training, held twice in 2016, with an associated online community of practice.³⁸

In 2016, the Robert Wood Johnson Foundation produced a report on 'The changing face of nursing: creating a workforce for an increasingly diverse nation'.³⁹ It provided examples of initiatives to widen access to nursing careers, including:

the use of holistic or whole-file review to overcome the barriers created by reliance on grade point averages (GPAs) and standardised test scores, for example by the University of Illinois at Chicago (UIC) College of Nursing, which adopted holistic review in 2013

Nicole Wertheim College of Nursing & Health Sciences' initiative to expand the number of men and increase minority enrolment in its BSN degree programmes through:

reaching out to occupational sectors that are predominantly male –veterans, paramedics and firefighters, and foreign-trained physicians

creating accelerated programs to attract these potential candidates.

Australia

Nurse roles and qualifications

In Australia, an assistant in nursing (AIN) works as a member of the nursing team and assists nurses to give general patient care. AINs need to complete a Certificate III in Health Service Assistance (a TAFE – Technical and Further Education – qualification). This can also be a pathway into a career in nursing or midwifery.

An enrolled nurse (EN) is a second-level nurse who provides nursing care, working under the direction and supervision of a registered nurse. ENs need to complete an 18-month or two-year course at TAFE or related health facilities to achieve a Diploma in Enrolled Nursing. This can also be a pathway into a career in nursing or midwifery.

A registered nurse requires a Bachelor Degree in nursing.

Recognition of prior learning (RPL)

The Australian Nursing and Midwifery Accreditation Council (ANMAC) is responsible for the accreditation of all nursing and midwifery education providers and programmes of study in Australia.

ANMAC supports the principles of recognition of prior learning (RPL) and credit transfer to facilitate the entry to and progression of students through nursing or midwifery qualifications (Bachelor of Nursing or Bachelor of Midwifery) by awarding credit for learning outcomes already achieved.⁴⁰ Prior learning can be formal or informal learning.

Credit transfer is defined in the Australian Qualifications Framework (AQF) as:

'a process that provides students with agreed and consistent credit outcomes for components of a qualification based on identified equivalence in content and learning outcomes between matched qualifications.'

RPL is defined in the AQF as:

'an assessment process that involves assessment of an individual's relevant prior learning (including formal, informal and non-formal learning) to determine the credit outcomes of an individual application for credit.'

RPL may include previous formal learning, previous informal learning (e.g. through work experience) and previous non-formal learning (e.g. through a structured programme that doesn't lead to an accredited qualification).

ANMAC requires education providers to demonstrate that RPL and credit transfer are applied in an equitable, flexible, reliable and valid manner.

Health authorities and academic institutions encourage Aboriginal people into health careers through support and advice. Further information can be found at the following websites.

the Western Australia Aboriginal pathways website⁴¹

Career pathways for Aboriginal people in NSW Health⁴²

NSW Aboriginal nursing and midwifery cadetship program⁴³

The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM).⁴⁴

New Zealand

Nurse roles and qualifications

The Nursing Council of New Zealand ('Nursing Council') is responsible for the registration of nurses, including enrolled nurses and registered nurses. It prescribes the qualifications required, and accredits and monitors educational institutions and degrees, courses of studies, or programmes. Enrolled nurses are required to complete a Diploma in Enrolled Nursing. Registered nurses are required to complete a Bachelor Degree in nursing.

RPL

The Nursing Council stipulates⁴⁵ that each school must have a RPL policy and procedure against which to assess individual student applications. Prior learning may include qualifications, life experience, work experience or other educational experience.

The Mãori Health Workforce Development Unit (MHWDU) at Otago University aims to support Mãori academic excellence in Health Sciences and increase the Mãori health workforce through a number of tailored programmes. Further information can be found at the following websites.

The Mãori and Pacific Admission Scheme (MAPAS)⁴⁶

Ngã Manukura o Ãpõpõ⁴⁷

Canada

Nurse roles and qualifications

Registered practical nurses (RPN) in Ontario and Quebec and Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN) in other Canadian provinces must 'graduate from an approved practical nursing program or equivalent'.⁴⁸ All Canadian provinces/territories (with the exception of Quebec) require a bachelor degree in nursing (BN or BScN) to become an RN.

There is no national registration/license in Canada. There are separate regulatory authorities within each province and territory for each of the three regulated nursing professions – LPNs, RNs and registered psychiatric nurses – except in Ontario, where the College of Nurses of Ontario regulates both RPNs and RNs.⁴⁹ However, there is a Canadian Practical Nurse Registration Examination and Canada uses the US NCLEX-RN as the Canadian RN entry-to-practice exam.

Pathways

In 2015, Nova Scotia published a report, 'Registered nurse education review in Nova Scotia', proposing a new model to improve undergraduate nursing in the province. The aims included to 'improve ability to transfer across programs and improve equity of access across the province'.

This included providing full recognition or specific block credit for prior learning.⁵⁰ The College of Licensed Practical Nurses of Nova Scotia provides regular updates on progress, with an LPN to BScN bridging programme.⁵¹

Education institutions in Canada recognise prior learning through Prior Learning Assessment and Recognition (PLAR), which is described as:⁵²

'a process that helps adult learners to identify, articulate and demonstrate relevant learning acquired through life and work experiences and translate this learning into college credit.'

Ireland

Nurse roles and qualifications

Registered nurses are degree-educated and registered with An Bord Altranais/Nursing and Midwifery Board of Ireland (NMBI).

Pathways

The NMBI stipulates that HEIs should demonstrate 'a commitment to fair and transparent processes for student admission, entry, transfer, discontinuation and completion'. Indicators to demonstrate this commitment include:⁵³

'Flexible modes of entry – for example mature students, FETAC, access, graduate entry – and clear procedures for Approval of Prior Learning (APL) are specified and have been approved by NMBI.'

England

Nurse roles and qualifications

Care assistants have no registration or fixed title, although a care certificate was introduced in March 2015. Registered Nurses are degree-educated, registered with the Nursing and Midwifery Council.

Pathways

The Willis report's recommendations included:⁵⁴

Health Education England (HEE) should evaluate the impact of the care certificate (introduced March 2015) and, subject to the evaluation, government should ensure that it is a mandatory requirement

NHS England should agree titles and job descriptions that align with HEE's development of a career and education framework for care assistants

care assistants should be offered APEL that could account for up to 50% of the undergraduate nursing degree

HEE, in collaboration with employers and HEIs, should support the development of more innovative work-based learning routes.

In December 2015, the UK Government announced a plan to create a new nursing support role – nursing associates – that will be regulated by the NMC. The role is intended to help bridge the gap between healthcare support workers, who have a care certificate, and registered nurses. It is intended that it could also be a new route for those wishing to become a registered nurse.⁵⁵

In November 2016, the UK Government announced the introduction of nursing degree apprenticeships. Apprentices will be released by their employer to study part-time in a higher education institution and will train in a range of practice placement settings.⁵⁶ They are expected to begin in September 2017.

The NMC provided guidance to nurse education providers on accreditation of prior learning (APL) in circular 01/2011 and its annexe.⁵⁷

Part-time programmes

Mature students have the benefit of life experience, emotional maturity and intrinsic motivation and have the potential to be a sustainable workforce as they tend to work locally and stay in the profession longer.⁵⁸ However, many have life commitments but are expected to fit into existing programmes that have limited flexibility. Part-time programmes may be an option for potential students who cannot commit to a full-time conventional programme.

Draper et al.⁵⁹ conducted a qualitative study to explore the impact of the Open University's pre-registration programme on students' employability, career progression and contribution to the UK workforce. Alumni (n=17) and employers (7) were interviewed >2 years post qualification. Themes identified included transition, expectations and learning for and in practice, and flexibility. Employers found the part-time programme provided the flexibility to grow their own workforce. Alumni reported that it provided them the opportunity to achieve their ambitions which could not have been achieved through conventional routes due to personal circumstances.

Implications for the project arising from this rapid review include:

the development of clear definitions of the target groups for widening access to pre-registration nursing and midwifery programmes are required to influence recruitment strategies

mapping of the current access routes to pre-registration nursing and midwifery programmes

a review of alternative entry qualifications and admission processes of HEIs

an understanding of the current provision of flexible/non-conventional programmes (e.g. part-time).

Footnotes

1. 'Articulation' is used in this report to describe the seamless transfer of students between stages of education, leading ultimately to entry into nursing and midwifery degree-level programmes.

2. Scottish Government. Nursing 2030 Vision. Edinburgh: Scottish Government; 2017
(http://www.gov.scot/Publications/2017/07/4277).

3. Scottish Government. National Health and Social Care Workforce Plan – Part 1: a framework for improving workforce planning across NHSScotland. Edinburgh: Scottish Government; 2017
(http://www.gov.scot/Publications/2017/06/1354).

4. Scottish Government. Best Start: a five-year forward plan for maternity and neonatal care in Scotland. Edinburgh: Scottish Government; 2017
(http://www.gov.scot/Publications/2017/01/3303/downloads).

5. Scottish Government. Plan for Scotland: the Government's Programme for Scotland 2016–17. Edinburgh: Scottish Government; 2016
(http://www.gov.scot/Resource/0050/00505210.pdf).

6. Scottish Government. Health and Social Care Delivery Plan. Edinburgh: Scottish Government; 2016
(http://www.gov.scot/Resource/0051/00511950.pdf).

7. Scottish Government. Developing the Young Workforce Strategy. Edinburgh: Scottish Government; 2014
(http://www.gov.scot/Publications/2014/12/7750).

8. Scottish Government. A Blueprint for Fairness. Edinburgh: Scottish Government; 2016
(http://www.gov.scot/Resource/0049/00496535.pdf).

9. Boliver V et al. Mapping and Evaluating the Use of Contextual Data in Undergraduate Admissions in Scotland. Durham: Durham University; 2017
(http://www.sfc.ac.uk/access-inclusion/contextualised-admissions/evaluating-contextual-admissions.aspx).

10. The Commission is grateful to David Robson and Victoria Loughlan of the Scottish Government for this definition.

11. Nursing and Midwifery Council. The NMC Register 2012/13–2016/17. London: NMC; 2017
(https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/nmc-register-2013-2017.pdf).

12. These figures do not include registered specialist community public health nurses (SCPHN), nurses and midwives with joint registration, and nurses and midwives or those with joint registration who are also registered SCPHNs.

13. Nursing and Midwifery Council. The NMC Register 2017. Scotland. London: NMC; 2017.

14. Scottish Care. Independent Sector Nursing Data 2017. Ayr: Scottish Care; 2017
(http://www.scottishcare.org/wp-content/uploads/2017/11/Nursing-Survey-Data-Report-Nov-2017.pdf).

15. Nursing and Midwifery Council. The NMC Register 2012/13–2016/17. London: NMC; 2017.
(https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/nmc-register-2013-2017.pdf).

16. Information and Statistics Division, October 2016 figures.

17. Boliver V et al. Mapping and Evaluating the Use of Contextual Data in Undergraduate Admissions in Scotland. Durham: Durham University; 2017
(http://www.sfc.ac.uk/access-inclusion/contextualised-admissions/evaluating-contextual-admissions.aspx).

18. Source of SIMD data is the Scottish Funding Council.

19. This is not the case for all students: those in FEI settings are not always entitled to this funding, which appears to apply only to HEI students.

20. Health Education England. Raising the Bar. Shape of Caring: a Review of the Future Education and Training of Registered Nurses and Care Assistants. London: Health Education England/NMC; 2015
(https://www.hee.nhs.uk/our-work/developing-our-workforce/nursing/shape-caring-review).

21. Scottish Care. Voices from the Nursing Front Line. Ayr: Scottish Care; 2016
(http://www.scottishcare.org/wp-content/uploads/2016/11/SC-Voices-from-the-Nursing-Front-Line-.pdf).

22. Universities Scotland. Working to Widen Access. Edinburgh: Universities Scotland; 2017
(https://www.universities-scotland.ac.uk/wp-content/uploads/2017/11/Widening-Access-A5-Leaflet-digital.pdf).

23. The consultation is running to 23 January 2018 – access at:
https://consultations.dh.gov.uk/professional-regulation/regulatory-reform/

24. Currently, no articulation route into the undergraduate midwifery programme exists.

25. Graduateness is defined as: '... the successful attainment of a higher education degree. From that educational process graduates develop key attributes. Those attributes may be common to all graduates, shared among those who have studied related subjects or be subject specific. These transferrable skills-sets and attitudes are markers of graduate-level performance and/or disposition, contributing to making these individuals desirable to employers.' (Definition taken from the report Graduateness: a systematized literature review of the concept applied to nursing in the United Kingdom by Dr Mike Ramsay, University of Dundee, March 2016.)

26. Buchan J. Solving nursing shortages: a common priority. Journal of Clinical Nursing 2008:17(24):3262–8.

27. Birkhead S et al. A model of practical nurse to registered nurse educational articulation: a successful approach to advancing the workforce. Teaching and Learning in Nursing 2016;11:152–6.

28. Department of Health. The Cavendish Review: an independent review into healthcare assistants and support workers in the NHS and social care settings. London: Department of Health; 2013.

29. Bureau of Labor Statistics, Occupational Outlook Handbook
(https://www.bls.gov/ooh/healthcare/licensed-practical-and-licensed-vocational-nurses.htm#tab-4).

30. Bureau of Labor Statistics, Occupational Outlook Handbook
(https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-4).

31. American Nurses Association, How to become a nurse (webpage)
(http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/RegisteredNurseLicensing.html).

32. Bureau of Labor Statistics, Occupational Outlook Handbook
(https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-4).

33. Bureau of Labor Statistics, Occupational Outlook Handbook
(https://www.bls.gov/ooh/healthcare/licensed-practical-and-licensed-vocational-nurses.htm#tab-4).

34. American Association of Colleges of Nursing (AACN), Accelerated nursing programmes (webpage)
(http://www.aacn.nche.edu/students/accelerated-nursing-programs).

35. AACN (2017), Diversity, Inclusion, & Equity in Academic Nursing: AACN Position Statement
(http://www.aacn.nche.edu/media-relations/AACN-Position-Statement-Diversity-Inclusion.pdf) (page 2).

36. AACN, Holistic Admissions Review in Nursing (webpage)
(http://www.aacn.nche.edu/education-resources/holistic-review).

37. Urban Universities for HEALTH (2014), Holistic Admissions in the Health Professions: findings from a national survey
(http://urbanuniversitiesforhealth.org/media/documents/holisticadmissionsinthehealthprofessions.pdf).

38. AACN, How has holistic review been used in nursing (webpage)
(http://www.aacn.nche.edu/education-resources/holistic-review/nursing).

39. Robert Wood Johnson Foundation (2017), The changing face of nursing: creating a workforce for an increasingly diverse nation (Charting Nursing's Future, Issue No 27 Jan 2016)
(http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf425988).

40. Further details at Australian Nursing and Midwifery Accreditation Council (ANMAC), (2015), Credit Transfer and Recognition of Prior Learning in Bachelor of Nursing and Bachelor of Midwifery Programs
(https://www.anmac.org.au/sites/default/files/documents/20150821_Expl_Note_Cred_Tfer_RPL_1.pdf).

41. Western Australia Aboriginal pathways
(http://ww2.health.wa.gov.au/Careers/Aboriginal-pathways).

42. Career pathways for Aboriginal people in NSW Health
(http://hire.steppingup.health.nsw.gov.au/career-pathways-aboriginal-people-nsw-health/).

43. NSW Aboriginal nursing and midwifery cadetship program
(http://www.health.nsw.gov.au/nursing/aboriginal-strategy/Pages/aboriginal-cadetships.aspx).

44. CATSINaM, Recruitment and Retention Position Statement
(http://catsinam.org.au/static/uploads/files/recruitment-and-retention-endorsed-march-2014-wfptinaomexg.pdf).

45. Nursing Council of New Zealand (2002, amended April 2017), Handbook for nursing departments offering programmes leading to registration as an enrolled nurse or a registered nurse
(http://www.nursingcouncil.org.nz/Education/Schools-Handbook).

46. The Mãori and Pacific Admission Scheme (MAPAS)
(https://www.fmhs.auckland.ac.nz/en/faculty/for/future-undergraduates/maori-and-pacific-admission-scheme.html).

47. Ngã Manukura o Ãpõpõ
(https://www.ngamanukura.co.nz/about-us).

48. Canadian Council for Practical Nurse Regulators, Become an LPN/RPN (webpage)
(http://www.ccpnr.ca/become-an-lpnrpn/).

49. Canadian Council for Practical Nurse Regulators, Become an LPN/RPN (webpage)
(http://www.ccpnr.ca/become-an-lpnrpn/).

50. Province of Nova Scotia, 2015, Registered nurse education review in Nova Scotia: final report
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