Nursing and midwifery - Listening Project: You shared, we listened

Executive Summary

In February 2023 the Ministerial Nursing and Midwifery Taskforce (the Taskforce) was established to build on efforts to make Scotland the best place for nurses and midwives to come and work. The Taskforce had the ambition to:

“recognise and value the contribution of the nursing and midwifery professions in Scotland by building sustainable and skilled nursing and midwifery workforces, with attractive, varied career choices across the four pillars of practice (clinical practice, facilitation of learning, leadership, and service improvement), fair work and flexibility, where all are respected and empowered, and where staff actively choose to stay in Scotland’s Health and Social Care workforce their whole career.”

The Taskforce was led by the Cabinet Secretary for Health and Social Care. It brought together workforce experts in nursing and midwifery, and representatives from health and care services, regulatory bodies, professional organisations, trade unions (Royal College of Nursing, Royal College of Midwives, Unison and Unite), academia, NHS Education Scotland and Scottish Government.

The Taskforce agreed to collaboratively develop a workplan of recommended actions to deliver short- and long-term change. To do so, four subgroups were established with each examining and making recommended actions on one of the four identified and agreed themes: Attraction, Education and Development, Wellbeing, and Culture and Leadership. Retention was identified as a key topic for each of the subgroups.

The Listening Project

To ensure the recommended actions of the Taskforce took account of the views from current and future nursing and midwifery staff, a series of engagement activities were organised under the banner of the Listening Project. These activities focused on identifying challenges that have an impact on the daily work and wellbeing of nursing and midwifery staff, students and academics and listening to the voices of staff on ideas to improve the situation. The Listening Project ran from August 2023 until June 2024 and consisted of three phases.

Phase one: Aug-Sept 2023

• Pulse Poll online survey (n=2818)

Phase two: Nov 2023- June 2024

• In person focus groups across Scotland with staff (n=462)
• National virtual focus groups with staff (n= 122)
• Free text online survey (n=607)

Phase three: February – May 2024

• Focus groups with students (n = 27)
• Focus groups with academics (n = 30)

The letter “n” is used to represent the number of participants or responses.

Listening Project strengths and limitations

A strength of the Listening Project was the interaction between staff, students, academics and the Scottish Government officials leading the focus groups which gave the opportunity to build rapport and take account of the wider context. Another strength was the extent of sample size, including participants from a wide variety of settings and roles across the whole of Scotland. Multiple data collection techniques were used, which collectively allowed for a comprehensive picture of the experiences of midwifery and nursing staff, students and academics. It also enabled data triangulation by comparing different datasets and the findings with the wider literature.

Involvement in the Listening Project was voluntary and depended on the willingness and availability of the participants. Due to the nature of the job, it was recognised that frontline staff might have found it difficult to attend in-person focus groups. To counteract this, additional virtual focus groups were held, and an online survey was also set up. This helped to increase the opportunities to take part.

Midwives and nurses from NHS, social care, independent and third sectors were invited to take part. However, it is important to record that, overall, only a small number of participants were employed within social care, the independent or third sector environment. Due to capacity and the timelines for this project it was not possible to extend recruitment to address this. Therefore, the findings in this report reflect mainly the perceptions of the NHS workforce.

Listening Project outputs

Analysis and reporting took place throughout the Listening Project and preliminary findings were shared and discussed with the Taskforce subgroups to help shape discussions on the proposed recommended actions.

This report presents the overarching issues and experiences heard in each phase of the Listening Project. These include views heard consistently across the different settings and roles, as well as views shared by small numbers of midwifery and nursing staff and/or students and academics, to ensure different views are represented.

Whilst the professions of midwifery and nursing differ significantly in many aspects, as do the fields of nursing, there were many areas of similarity, irrespective of field or profession. Both differences and similarities in the views heard have been highlighted.

Most of the issues raised in the Listening Project engagement activities related to broader workplace and education factors that impacted on the way that those who took part perceived their ability to do their job, study, deliver education or, more simply, in the way they felt valued. As a result, comments on organisational cultures, working environments and leadership styles were often similar across health boards, settings and roles. Comments from students and academics often transcended fields of practice and profession.

While participants raised many negative points and/or issues of frustration, it shone through that those who took part in the Listening Project genuinely cared about the nursing and midwifery professions and the work that they do.

Listening Project key messages

Nursing and midwifery staff – key messages

• Staff love what they do but feel that the system they are working within and the pressure they are under is making it harder to feel like that. They want to enjoy their role (again) and encourage others into the career.
• Staff want to be able to manage their own wellbeing with support in place but do not appreciate when self-care initiatives are put in place, rather than fixing challenging working environments.
• Staff want to be able to have more flexibility to manage their working hours with their personal circumstances at that time (e.g. caring responsibilities, commuting, physical ability).
• Many staff were positive about career development, but this was not always available consistently or universally, especially in more rural areas. Finding time to undertake both mandatory and developmental training is difficult, and inconsistent with other job families.
• Staff want to be able to deliver good quality care which involves spending sufficient time with patients. However, inefficient IT systems and often multiple data input requirements are time consuming and detract from this and can often lead to duplication of work.
• Staff tend not to feel safe when moved to cover staffing gaps in an area they are not familiar with.
• Staff highlighted supportive team relationships as being a positive. However, bad behaviours are very difficult to challenge, and when challenged are not necessarily dealt with.
• Staff do not feel informed about decisions that affect them (often due to a top-down approach). Suggestions by staff were often not listened to or acted upon.
• Staff feel there are some great examples of leaders within organisations, but feel that leadership is not always consistent, or that the right people are in, or attracted to, leadership roles.
• Some staff in senior roles feel sandwiched between pressure from managers above them, as well as from the staff they manage, and acknowledge that they do not always have the time to support staff.
• Staff feel that it can be difficult to provide support for students and newly qualified staff due to the pressures they are under to manage their own workload. Newly qualified staff are often required to supervise students when they are trying to learn their own job and can find themselves being the most experienced member of staff a short time after graduation.

Midwifery specific key messages

• Staff find it increasingly challenging to give the required care for women in the time allotted due to an increase in both medical complexity and social challenges of the women they care for which impacts on predicting staff requirement.
• Some staff raised concerns about the skill mix within teams which can leave more experienced staff feeling vulnerable in their working practice.
• Loyalty to teams came across strongly in many areas. However, a number of staff also raised cultural issues with a “them and us” atmosphere between hospital-based and community-based staff. A cliquey culture was also raised as a negative feature.
• Some staff gave examples of good leadership. However, the feeling of a “blame” culture was also raised.
• Staff talked positively about clinical supervision and highlighted that this has been embedded into practice. However, an issue raised by some staff was around the information around career progression not being clear. There is a lack of consistency in promoted roles available across NHS Scotland and clear pathways to move into these roles.
• Issues around rotational contracts were raised with staff reporting that the good intentions of implementation were not always realised and came with drawbacks.

Midwifery and nursing students – Key Messages

• Overall students enjoy their programmes, especially time in practice and learning from experienced practitioners.
• Students value opportunities to practice skills in the safe environment of clinical simulation as this makes them feel more prepared for the real-life practice environments; midwifery students however feel this option is limited for them and would like more simulation to feel better prepared.
• Students want to feel welcome in the practice learning environment and want to feel part of the team.
• Students feel concern for registered nurses and midwives and their workload, but also feel concern that they retain their supernumerary status, and often feel unsupported due to staff workload.
• Students worry about finance and feel this negatively impacts on their ability and motivation to study and practise in the professions.

Nursing and midwifery academics – Key Messages

• All academics reported that workload was excessive, indicating that this was at times detrimental to both the health and well-being of staff.
• Academics recognised the need for a focus on progression and retention of students, but also highlighted the importance of values-based recruitment and selecting candidates with the values required for the professions.
• Academics recognised the negative image of the professions in the media, indicating that this presented problems for recruitment to programmes and for retention on programmes and in the workforce, suggesting that this needs to change.
• Academics valued opportunities for research and to develop the professions but expressed concern about the limited and unclear pathways for career options and entry into academia and education.

Conclusion and next steps

The feedback from nursing and midwifery staff, students and academics was collected over several months and was fed back into the Taskforce subgroups on a continuous basis to inform their discussions on possible recommended actions. The Taskforce collectively considered the recommended actions proposed by all subgroups which will be published in a separate report.

Inevitably issues outside the scope of the Taskforce were raised during the Listening Project. These were shared with the relevant people outside the Taskforce, taking care to protect the anonymity of those who participated and their employing organisation. When an issue raised was deemed serious enough to require further escalation for follow up, permission was sought from participants and any identifiable information about the respondents was removed prior to this escalation. In all Listening Project matters, public protection and protection of those who took part remained at the forefront throughout the project.

The Listening Project was established to ensure that the voice of staff, students and academics were heard as part of the Taskforce. Therefore, it was decided to publish the full report of the Listening Project as it formed a key strand of evidence for consideration by the Taskforce. The report will also be shared with staff to assure them that the feedback they gave has been captured and shared widely as part of the Taskforce work. It is also hoped that the Listening Project format will be used again in the future as part of policy development.