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

Appendix One: Technical methods

Recruitment of the listening project participants

The Listening Project was the mechanism to gather views from the current and future workforce to help shape recommendations stemming more broadly from the Taskforce.

The Listening Project was for all nursing and midwifery staff, academics and students, including healthcare and maternity assistants in Scotland and spanning all areas of practice. The focus was on hearing from a diverse range of perspectives from across services and different geographical locations to obtain in-depth insights into the joys and challenges they experience in their daily work or study, and suggestions to improve the situation. The idea was to create many opportunities to listen and learn from students and staff to gather their thoughts to feed into this process. This resulted in over 4,000 engagements with the Listening Project. Due to the way the Listening Project was set up it was possible to participate in more than one Listening Project engagement activity (but only once in the focus groups).

The links to the online Pulse Poll and free text surveys were distributed through the members of the Taskforce, sub-groups, Health Boards, and word of mouth. The link to the free text survey was also shared by participants of the focus groups with nursing and midwifery staff.

Focus groups and survey with nursing and midwifery staff

Nursing and midwifery staff were invited into the focus groups through the executive nurse and/or midwifery directors who were approached by the Listening Project team by email. To identify a range of views from participants with a wide range of experiences, focus groups were organised in all territorial health boards and (most) national health boards, and with some specific professional groups. This was done to ensure that the sample included staff from all health board areas in both acute and community settings, and with representation from staff across nursing and midwifery.

Participation in the Listening Project was voluntary and depended on the willingness and availability of the participants. Due to the nature of the job, frontline staff might have found it difficult to attend the in person focus groups. To counteract this, additional focus groups were held, including virtual ones and the supporting survey (with open questions similar to those asked in the focus groups) was set up which helped to increase the opportunities to participate. Also, at times participating staff had gathered views from colleagues who could not attend and shared these.

Focus groups with nursing and midwifery students and academics

For the focus groups with nursing and midwifery students and academics the focus was on selecting participants from different Higher Education Institutes (HEIs) and across different year groups. The participating nursing students represented all four fields of nursing practice and all four years of nursing programmes. Geographically, these nursing students also represented the North, East and West of Scotland. However, recruiting midwifery students proved more challenging. With the support of RCM, 1 focus group with midwifery students took place. These students represented 3 HEIs and, geographically, represented the North, East and West of Scotland.

The Council of Deans Health (Scotland), with the Royal College of Midwives (RCM) supported the recruitment process of nursing and midwifery students and academics.

The facilitation of the focus groups

All focus groups were facilitated by Scottish Government staff. Key open questions were generated to initiate a conversational approach, the aim being to enable the participants to provide more detailed answers as the focus groups progressed. Time was given to raise issues of importance and it was not always necessary to ask every question or to prompt participants to respond, mainly as areas of concern or importance were often communicated freely as the conversation took place. Care was taken to develop an informal approach and build rapport. This approach led to in-depth discussions. During and after the discussions it was clear that people appreciated being asked about their views and share their experiences.

The approach to analysis

The analysis of the gathered information started soon after completion of phase one of the Listening Project. The Pulse Poll and free text survey datasets were managed via Microsoft Excel and SPSS. Descriptive statistical analysis (frequency tables and cross tabulations) was used to analyse the closed questions.

Free text responses were analysed by using a thematic approach described by Braun and Clark (2006). This method entails identifying patterns and differences in the data within and between different groups of respondents. Due to time constraints, the free text comments were also mainly analysed using a quantitative rather than a qualitative methodology.

Phase two generated a large amount of data. Key elements of the analysis were:

• Throughout the focus groups the team discussed their own perceptions on the topic and kept memos to track biases and develop ideas and emerging themes.
• The information gathered was also sorted by developing an issues log.
• To avoid clustering by levels of seniority issues raised were also looked at by banding/ years qualified.
• After careful reading and rereading a selection of field notes and transcripts an initial coding framework was developed guided by the sub-groups’ themes of Attraction, Retention, Education and Development, Wellbeing, Culture and Leadership (see below). However, once it became clear that many of the issues raised covered more than one sub-group theme, the conceptual checklist on retention by Buchan and Catton (2018, 2023) was used to guide the interpretation of the gathered information.
• Deviations in the data were explored and discussed by the team.
• The outcomes were discussed throughout the Listening Project within the Listening Project team, and with the sub-groups and Taskforce when pre-liminary findings were fed back.

Reflective of qualitative methodology, the participants in the Listening Project were not intended to be a random representative sample of the entire workforce. Instead, there was broad representation from different geographical areas, job families, years’ of experience and banding. Having said this, many of the issues and challenges that were raised were similar across the boards though the angle could vary depending on, for example, location or level of seniority.

Initial coding framework in question and answer format

Attraction and Retention

1. How can we attract more people into nursing and midwifery?

• By highlighting the rewarding aspects of the roles, such as:
• “No two days are the same”
• There are opportunities to progress or have multiple careers.

“It’s fantastic to care for people”

It’s key to give a balanced picture. While many mentioned positive aspects, everyone reflected on challenges.

• By matching the reality with the (created) expectations of the roles:
• Align University programmes with the practical nature of the profession.
• It was noted that people leave when the working environment didn’t meet their expectations or when the challenging aspects outweighed the rewarding aspects.

Job descriptions need to reflect the actual job.

2. How can we support retention of the existing workforce?

• By having a solid support structure and induction programme for students and NQS and having more opportunities for those thinking about retirement
• By having flexible working patters and shifts

There is a noticeable imbalance between experienced and inexperienced staff.

Education and Development

1. How can the workplace contribute to the staffs’ education and development?

• By implementing time for staff’s study and training across the organisation
• There is an ongoing expectation to learn additional skills, which often seem to be taken for granted by management.
• By raising awareness of different specialities and having clearly defined career pathways
• Becoming stuck in one’s job or speciality (for example by lacking access to relevant or existing courses) was not uncommon.

Boards and departments vary in providing study time, leaving many to catch up in their own time.

Being able to specialise and/or move to different areas was perceived as a positive of the job and a way to support retention.

2. How can staff be supported to provide students with a good learning environment?

• By having protected time to mentor students
• Less paperwork when the student fails the performance.
• By teaching students the appropriate social and clinical skills

The work pressure impacts on expected time to spend with students.

and supporting staff to cope with those students who lack these skills.

Wellbeing

1. In what ways do the current working conditions reduce staff’s wellbeing?

• By working under pressure with high levels of unpredictability, due to:
• Moving staff from their team to cover in a different area is a major stress factor.
• Time-consuming aspects, e.g. IT systems, record keeping, duplication.
• Persistent workload without ability to take a break.
• By not feeling valued, respected, and supported
• Lack of basic facilities.
• External factors, e.g. a more complex patient population, increased workload since COVID, high patient expectations (constantly apologising).
• Too much pressure leads to the feeling of firefighting.

Unrealistic expectations to give patient care without enough staff and resources.

Receiving no acknowledgement for input (“caring aspect held against us”).

2. In what ways can the current working conditions support staff’s wellbeing?

• By being able to look after patients within the time given
• By being able to go to the manager when stressed.
• By encouraging peer support within teams and across the organisation
• Initiatives such as yoga are perceived as helpful but not for addressing the cause of poor wellbeing.

Caring for patients is why people stay.

Being in a supportive team was perceived as a coping mechanism.

Leadership and Culture

1. How is the senior management’s impact on the workplace culture perceived by the rest of the staff?

• Good experiences have a direct positive impact. Positive factors:
• Having a clear management structure.
• Building relations and co-operating.
• Giving direction on what is expected.
• Transparency around decisions.
• Giving constructive, positive feedback.
• Supporting (not blaming) staff.
• Adapting to the setting.
• Bad experiences have a negative impact. Negative aspects:
• Lack of visibility leads to lack of trust in managers’ decision making
• Not responding to concerns (silence).
• Having a long chain of command leads to us-them thinking.
• A poor managerial attitude leads to uncertainty, and poor wellbeing.

Being visible and hands on.

Taking away control to make (clinical) decisions without explanation.

2. What is the senior management’s perspective of their options to positively influence the culture?

• Navigating financial and clinical/human pressures and supporting staff is really challenging
• Being nice to staff and valuing them is crucial, “it is not rocket science”

Can lead to not feeling in control or perceiving fair managing as an impossible task.

Looking after the workforce starts with listening and responding to build safety/trust and consistency.