The commission on widening participation in nursing and midwifery education and careers

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

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 NHS Scotland:

• 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 NHS Scotland, 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 NHS Scotland 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 NHS Scotland
• tackle stereotypical images of nurses and midwives, creating a more positive professional role model.

2. In relation to attracting men to the professions, CNO should scope current best practice in this area and make recommendations for a national approach with realistic targets.

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 NHS Scotland 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.