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

2. The Pulse Poll online survey

Phase one of the Listening Project consisted of the Pulse Poll which sought to gather views on what the Taskforce should focus on. It was grouped as five topic areas: attraction to midwifery and nursing, education and development of the current and future workforces, wellbeing amongst staff, leadership and culture, and retention amongst the professions. The survey was circulated widely by Taskforce members, as well as members of the constituent groups they represented.

2.1 Demographic information

From the 2818 participants, the majority (79%) were employed by NHS Boards and 1875 (67%) worked in nursing and 220 (8%) in midwifery.

Nursing and Midwifery staff by role (NHS Board and General Practice)

Nursing (n=1875):

Senior Charge Nurses, Charge Nurses, Senior Nurses/Nurse Managers, Directors/Associate of Nursing, Nursing Support Workers, Staff Nurses, Advanced Nurse Practitioners, Clinical Nurse Specialists, General Practice Nurses, Nurse Consultants, District Nurses, School Nurses, Research Nurses, Family Nurses, Occupational Health Nurses, Trainees, Bank staff, Health Visitors, Practice educators, Other – Senior Professional Leaders

Midwifery (n=220):

Midwives, Maternity Support Workers, Senior Midwives, Heads of Midwifery, Practice educators, Other – Senior Professional Leaders

2.2 Attraction

Respondents were asked whether the following topics should be considered by the Taskforce.

• Agreement was high for all statements across all health boards, especially on attractive employment aspects.
• More nurses and midwives in leadership positions agreed with the statements than nurses and midwives in non-leadership positions. This was especially the case for “The way careers are marketed” and “The role nurses and midwives can play in promoting”.

A free text question asked: “what else should be considered by the Taskforce to attract people into nursing and midwifery?”, and 1809 (64%) responded. Respondents with more working years gave more comments than those who were newly qualified. Comments were categorised along five themes and are presented under the overall headings of “Attracting people into nursing and midwifery” and “Current system challenges”.

Attracting people into nursing and midwifery

• Features of media and recruitment campaigns (n = 425 / 23%)

Nearly a quarter (and particularly midwives in senior roles) commented on the need to use social media and digital platforms to attract new recruits into midwifery and nursing. Overall, it was deemed important to reflect the wide diversity of roles within the professions as well as appealing to a wider audience and being honest about the challenges of practice as part of campaigns:

“Honesty, difficult topics and challenges to be addressed, not glossed over. Real life interactions, this is not an office job. You need people skills” (midwife, 30+ years qualified).

“The majority of posters, adverts on TV and radio broadcasts I have seen/listened to still portray nursing as being a predominantly female profession. What qualities does a career in nursing have that can be marketed so more males apply?” (staff nurse, 21-30 years qualified)

According to these respondents, a major pull factor for attraction is the impact these professions have on people’s lives, providing both job satisfaction as well as public benefit. Showcasing real staff and service user stories to demonstrate the value of different midwifery and nursing roles was felt to be helpful. Respondents commented that it would be useful to target young people in schools and colleges to help inform and inspire them to study for midwifery and nursing degrees. Some however commented on the media as counteractive to attracting people into the professions.

“If the media stop making the professions look unattractive, we might actually be able to get somewhere.” (lecturer, 6-10 years qualified)

• Widening entry routes into nursing and midwifery (n = 165 / 9%)

According to respondents, and especially non-registered staff, increasing widening participation into the nursing and midwifery workforces would better reflect the diversity of Scotland’s population and would maximise recruitment opportunities for the workforce. Some suggestions included:

“Information and promotion of minority nurses, such as disabled nurses and the roles disabled individuals can make in the profession.” (student)

“There needs to be more scope for non-registered staff to undertake formal training and to discuss the routes available, OU etc.” (non-registered staff)

Other responses referred to the need to consider alternative modes of entry into the professions, such as reinstating apprenticeship models, development routes for non-registered staff, and further recognition of prior learning experiences:

“The concept of having to go to university has, for a long time, been a barrier to attracting people into the profession. Some people believe this is not achievable for them, others believe it’s not affordable. Addressing this has to be a key priority for the taskforce. The career pathway has to be more immersed in practice with a blended and modular approach to learning. It also has to return to paid employment which is non supernumerary but within a learning culture and with enough staff to enable positive learning in practice.” (senior professional leadership)

• Student bursaries and incentives (n = 109 / 6%)

In response to the question ‘what else might attract people into nursing and midwifery’, respondents, and particularly students, referred to the challenge of having to make ends meet whilst receiving a bursary. For example:

“Nursing bursaries in Scotland must reflect the current cost of living crisis. Returning to higher education is a massive financial commitment, many capable individuals are excluded from the profession due to financial struggles.” (student)

Current system challenges

• Existing employment practices (n = 875 / 48%)

Most who commented referred to current working conditions in their response, particularly within the staff nurse and practice nurse groups. Overall, many felt that existing employment practices in nursing and midwifery needed to change before extensive attraction strategies are put in place for future workforces. The level of dissatisfaction was high with negative comments about current managerial culture, unsafe staffing levels, poor remuneration, and lack of ongoing support. According to these respondents, these issues weighed against nursing and midwifery being seen as attractive careers, not only for potential candidates but also by those within the professions themselves. Hence, according to these staff, the key focus should be on addressing current system challenges to retain existing workforces rather than devising expensive new methods of attraction:

“We are too focused on attracting people in and not enough on retaining who you have! You cannot keep feeding a leaking bucket.” (lecturer)

Poor staffing levels were noted to affect the support available to nursing and midwifery students whilst on placement:

“Looking at current morale in nursing, nursing students are being put off the job when on placement and there are limited staff on the floor and everyone is very stressed” (Senior Nurse/Nurse Manager, 11-20 years qualified).

Whilst employment factors such as flexible working patterns and positive working cultures were deemed critical, these did not seem to be the reality for some midwives and nurses in practice today:

“We need flexible working, improving shift patterns and family friendly schemes, better pay and conditions.” (midwife, 11-20 years qualified)

Another key issue was the remuneration midwives and nurses receive which they felt is out of step with their skills, experience and the safety critical roles they undertake.

• Career pathways and routes to progression (n = 224 / 12%)

There were 224 comments (12% of total) about the need for clearly aligned career pathways particularly among midwifery staff. Many felt that there was little or no opportunity for progression and there was, on occasions, a lack of clear demarcation between one staff member, in terms of Agenda for Change Band grading, and another. Reference was sometimes made to ‘being stuck’ in the same pay Band without access to promotion or supported education. This comment applied to registered nurses as well as to non-registered staff.

“There is no progression to better salary as the expectation of my role increases – I've been at band 5 for 20 years. Expectation e.g. now expected to do nurse led clinics. Used to be a band 6 job now a band 5 job so no wage increase … not good.” (staff nurse, 21-30 years qualified)

2.3 Education and development

Respondents were asked whether the following topics should be reviewed by the Taskforce.

• Agreement was particularly evident with ensuring positive learning environments for students and promoting development for staff.
• Academics were more inclined to favour opportunities to engage in research.

Nearly half the participants gave a response (n=1283, 46%) to the open question “what else should be considered regarding education and development”. These have been categorised in five themes.

• Protected time for learning (n = 364 / 23% of the sub sample)

Most comments related to the request for protected time for education and development and included staff needing time to undertake study for themselves, but also to support nursing and midwifery students. It is noteworthy that even undertaking mandatory training for some respondents was impossible in their current work role.

“Staffing levels often prevent staff attending courses/study days etc. We expect staff to keep updated yet we put many obstacles in their way… If we want to retain staff, we need to make it easier for them to stay in the profession, advance in their career and have various opportunities for CPD.” (senior charge nurse/ community leader, 30+ years qualified)

“Student nurses are currently being utilised as non-registered staff due to staff shortages so learning opportunities are few and far between on placements - this needs addressed with some urgency.” (student)

• Flexibility of education to fit individual circumstances (n = 245, 19%)

This theme comprised of a variety of factors including: the need for flexibility in the delivery and timing of education, the format and level of study offered, and recognition that individuals may want to choose their own study entry and exit points learning activities, modes of assessment and types of educational resources. Students in particular commented regarding these aspects.

“[There needs to be a] range of practical training opportunities that are as valued as academic learning, not all nurses wish to be working/study to Advanced Nursing Practice/Masters degree level.” (senior practice nurse, 21-30 years qualified)

• Help with funding (n = 244 / 20%)

Funding was also a source of dissatisfaction and financial support was deemed to be required for formal education and development courses, backfill of posts and secondment opportunities. This was particularly mentioned by students and midwives in response to the question “what else should be considered regarding education and development”:

“More funding for training and development at all levels. An example. I was told I needed a certain qualification for a role I had been doing for nearly 2 years on a temporary promotion before I would be considered for interview for the permanent post, but I was expected to pay for most of it myself. Up to £6,000. I don’t mind studying but if it is deemed necessary for a post we shouldn’t be expected to pay for it personally.” (senior nurse, 21-30 years qualified)

• Equality of access (n = 193 / 15%)

According to these respondents improvements were needed to the accessibility of education. There were equality issues between professions, between fields of practice, between grades and between locations. These appeared particularly acute for midwifery:

“Equal opportunities for nurses and midwives compared with medical counterparts [need to be considered]. Dedicated professional development time and support for further studies / CPD.” (lecturer, 30+ years qualified)

• Valuing education and development (n = 170 / 13%)

These comments related to the value of education and development of staff as well as the positive impact it can have on patient outcomes. Most of the responses came from those in the nursing profession. Respondents were particularly frustrated when their postgraduate qualifications were not rewarded with extra pay or promotion opportunities.

“Reward education with salary increase and career progression - too many nurses are stuck at band 5 and 6 despite postgrad education.” (staff nurse, 30+ years qualified)

“Having a workforce that are fit to practice, able to provide the best care possible, you need to provide consistent on the job training opportunities and supernumerary time.” (practice educator, 21-30 years qualified)

2.4 Wellbeing

Respondents were asked whether the following topics should be reviewed by the Taskforce with:

• Agreement was high for all statements related to wellbeing. There was least agreement on clarifying the definition among students (75%) and health visitors (73%).

Around 43% (n= 1215) added comments on the open question “What else should be considered by the Taskforce regarding staff wellbeing?”. Comments were categorised in 4 themes. There were no differences in responses between those in nursing and midwifery.

• Need for support to promote wellbeing at work (n = 425 / 35%)

According to these respondents, support was required to promote wellbeing amongst staff. This theme related to many different types of support, including both formal and informal mechanisms, accessible resources, as well as visible role modelling by managers. A key finding was the importance staff placed on having access to a supportive infrastructure to help them deal with the physical and emotional burden of delivering care. The need for positive engagement by managers was frequently mentioned as was the perception that specific contributions at work were rarely valued at this level:

“The management should be providing more positive feedback and encouragement rather than only pulling staff into the office for reprimands/investigations.” (staff nurse, 3-5 years qualified, independent sector care home)

“Nurse managers should keep updated with clinical skills so that they can help out. Senior nurse managers need to do more walkabouts, ward rounds - get to know the staff more.” (advanced nurse practitioner, 30+ years qualified)

• Social factors affecting wellbeing (n = 348 / 28%)

A closely related theme to support were requests from respondents to take the wider environmental and cultural factors into account when considering wellbeing. For many, staff wellbeing was seen to be the consequence of establishing positive healthy workplaces. As such, there was a strong demand for change to be implemented at the level of health boards rather than an undue focus on individual factors. For example, one respondent commented on the importance of culture:

“Everyone needs to understand culture and what they individually and collectively bring to a culture. Person-centredness influences all areas of practice and should be evident from CNOD, Boards, units, wards, clinics etc!” (lecturer, 30+ years)

• Pressurised workplace settings (n = 304 / 25%)

A multitude of comments in response to the open question on wellbeing referred to working in pressurised workplace settings:

“The fact is that staff wellbeing is impacted by the pressure and expectations of the roles. It is a vicious circle and that is why staff are leaving the NHS, so the low staffing levels persist, putting excess strain on existing resources.” (senior nurse, 30+ years qualified)

• Specific facilities/benefits (n = 105 / 9%)

Other comments related to specific facilities or benefits and that these should be included in the workplace for midwifery and nursing staff to improve wellbeing. Suggestions ranged from onsite gyms, free car parking and break rooms, to more basic needs such as access to healthy food and drinking water.

“Proper facilities to ensure a relaxing break. Better access to healthy food. Reduced prices. Simple things like being able to park near where you work, working equipment, IT systems etc.” (advanced nurse practitioner, 21-30 years qualified)

• Resilience (n = 33 / 3%)

Comments on ‘resilience’ in relation to wellbeing showed that this term was polarising for respondents. Some thought that resilience was a key attribute for midwives and nurses. For others, a sense of ‘moral toughness’ was dependent on the environment and degree of challenges faced. They saw the expectation of resilience in a negative light, for example:

“[Do] not expect staff to work under crushing pressure then telling them they should be more 'resilient'.” (staff nurse, 6-10 years qualified)

2.5 Leadership and culture

Respondents were asked whether the following

• There was strong agreement for the Taskforce to review the factors that impact on creating a positive workplace culture (93%).
• Looking at the impact of a hierarchical culture was high across health boards, and highest for midwives in non-senior positions (88%).

The open question what else should be considered by the Taskforce regarding leadership and culture resulted in 1052 (37%) responses, which were indexed into 6 themes. There were no notable differences between the responses given by those within nursing and those within midwifery.

• Visible, hands-on leadership (n = 231 / 22%)

These respondents called for leaders to be much more visible, hands-on, and collaborative. There was mention that managers rarely visited front-line settings and were not approachable or prepared to help in any practical way. As such, the feeling was that senior staff were indifferent to the pressures that fell to practitioners and did not listen to, or act on, the concerns they raised. Several comments suggested that there were too many managers compared to patient-facing staff:

“Management needs to work much more closely alongside staff in departments & wards to fully appreciate & understand the pressures/workload/issues that staff have to deal with on a daily basis. They need to be familiar to the staff, be prepared to work hands on with them on a regular basis, be approachable & supportive etc.” (staff nurse, 30+ years qualified)

• Hierarchical models of leadership (n = 210 / 20%)

Hierarchical models of leadership in nursing and midwifery were deemed to prevail across both professions. There was much criticism of the so-called ‘command and control’ approach, typified by laying down demanding performance targets, leading from the front, being reluctant to delegate, and lacking collaborative practices. In several accounts, this dominant style was felt to lead to ‘toxic cultures and bullying behaviours:

“We need to move away from command and control and micro-management structures. It has a negative impact on staff wellbeing.” (staff nurse, 30+ years qualified, id 395)

• Creating positive workplace cultures (n = 164, 16%)

In the comments were calls for a more distributive leadership model across nursing and midwifery. From respondent accounts, this type of approach would delegate responsibility to frontline practitioners, instil collaboration and teamwork in workplaces and create cultures where the status quo can be challenged, ideas listened to, and innovation encouraged. For example:

“Hierarchical, status oriented, defensive cultures need to be broken down. There also needs to be a genuine focus on safety, learning and prevention instead of on blame and point scoring.” (senior healthcare support worker, 3-5 years)

• Leadership development (n = 168 / 16%)

According to this subsample there appeared to be some ambivalence amongst midwifery and nursing staff about taking up leadership positions because of salary discrepancies. Also, many felt that some type of development for these roles was necessary. Examples of responses were:

“Many leadership post results in a real time drop in salary due to absence of unsocial hours - this excludes / prevents many nurses with huge potential being able to progress” (senior charge nurse, 21-30 years qualified)

“Promotion, learning experiences and managerial skills should be offered to allow staff to be rewarded for their hard work. All mangers should have to complete the correct training and be proficient before being managers. Listening to and communicating with all grades of staff needs to be a priority.” (midwife, 21-30 years qualified)

• Lifelong leaders (n = 116 / 11%)

Some respondents noted that every member of staff working in midwifery and nursing performs as a leader in the health and social care sector at their own level. From this perspective, leadership was deemed not only to be the domain of senior staff, but all practitioners should be role models and given opportunities to voice concerns and challenge poor practice:

“Passionate about culture and leadership and a more unified approach [needs to be considered]. Opportunity and support for clinical healthcare professionals at all stages of their career to be part of culture and leadership exploration/shared learning/mentorship/coaching and programmes. (senior nurse, 21-30 years qualified)

• Appointing the right leaders (n = 115 / 11%)

Comments under this heading referred to the importance of appointing the right people for leadership roles. Successful leaders were viewed as those who are accessible, transparent, able to engage others by building and maintaining constructive relationships, willing to listen and involve others in decision-making processes. Interestingly, these comments suggest that the best leaders may not be those who apply for leadership positions. Some reported that it would be worthwhile to identify and grow talent to fill leadership positions in the future. Leaders were perceived to need a diverse set of abilities and skills to enable them to engage staff and effect change. Three of these essential attributes appear to be: identifying and communicating shared goals, asking and listening to others, and acting decisively whilst behaving with humility and fallibility. One respondent wrote:

“Leadership requires …. people and leadership….skills. People who have the best interests of their staff at heart will get the best from their staff. Staff feel unsupported today due to lack of training for the new charge nurses. Most have no idea about policies when they start these posts let alone how to deal with staff.” (staff nurse, 21-30 years qualified)

2.6 Retention

• There was strong support for the Taskforce to review the reasons why staff leave the nursing and midwifery professions and the factors that might encourage them to stay (95% agreed for both items).
• Looking at roles in rural communities was particularly high among Advanced Nurse Practitioners (91%) and Practice nurses (93%).

On the open question “What else should be considered about retention?” comments were given by 1073 participants (38% of sample) affecting both those in nursing and midwifery. The comments were categorised into three themes, which overlapped considerably with the comments given to the open question in the section on attraction.

• Improving existing working conditions (n = 759 / 71%)

Most comments under this theme focused on improving existing working conditions to increase staff retention. Many comments addressed the types of improvements deemed necessary for retention, such as pay and AfC Bands, with respondents referring to enhanced responsibilities in roles without commensurate increases in salary. Respondents also commented on people leaving because of the working conditions, for example:

“Many are leaving the profession as they do not feel supported. Students are being trained by newly qualified midwives who have no support from senior staff but are too scared/intimidated to report this.” (midwife, 6-10 years qualified)

There were also calls for more flexibility in shift times, better staffing levels and adequate support infrastructures for both staff and students. Some felt that visible management and listening to, and acting on, the views of staff would help midwives and nurses feel more valued.

“Listen to staff. In the last 10 years there has been less visibility of senior management team’s engagement with ‘shop floor’ people. The voice of the employee is not being heard.” (midwife, 30+ years qualified)

A number of responses referred to the ongoing support required particularly for new registrants:

“Structured approaches to education and development such as embedding clinical supervision and preceptorship may capture and address issues before it is too late. Address gaps between preparation and reality of being a nurse. Need to ensure that organisational expectations of younger workforce are realistic with investment in supervision and support.” (practice educator, 30+ years qualified)

The needs of older staff and the importance of retaining their experience were also cause for comment.

“Pension changes meant that a lot of staff retired and came back part time and I think this is a positive move for many. We should continue this as we keep their experience, knowledge and skills in the teams. We need teams with experienced staff to support new staff as they develop in their role.” (senior charge nurse / community team leaders, 30+ years qualified).

“Many staff with lots of valuable experience leave because there isn't enough flexibility for staff as they age. They should be accommodated so they remain in the organisation and pass on their knowledge.” (staff nurse, 30+ years qualified)

The distinct issues associated with working in rural areas also arose. These covered funding discrepancies, difficulties in recruitment as well as matters associated with retention:

“Allowing staff to be a part of the decisions around organisational change. In particular in more rural settings and where service needs will differ from inner city.” (school nurse, 11-20 years qualified)

“I feel that the Scottish Government very much believe that one size fits all and this is very much not the case. The roles of nurses and midwives in rural areas are much more diverse than that of colleagues in the cities.” (health visitor, 21-30 years qualified)

• Flexible return to work options (n = 97 / 9%)

Respondents looked positively at return to work initiatives such as ‘retire and return’ across the nursing and midwifery workforces. Some felt that, at the very least, the cost-effectiveness of such schemes should be assessed from both an organisational and employee perspective, as well as offering more flexibility and support to allow staff to return:

“Pension, flexible hours, 2-day posts would mean more would stay on.” (staff nurse, 30+ years qualified)

“Encouraging experienced nurses to return to work post-retirement has benefits not only for the person, the team, the organisation, but ultimately will have a positive impact on patient outcomes. More support needed here.” (practice educator, 30+ years qualified)

• Investigate why staff leave nursing and midwifery (n = 193 / 18%)

Comments under this theme related to the need to investigate and act on the results of exit interviews. For some, these investigations should assume in-depth analyses of staff turnover incorporating regional trends, fields of practice, specialities, age-bands, years employed/ qualified etc. Taking an honest and thorough approach was deemed to support retention strategies that could help the long-term integrity of the workforce:

“Listen to the reason why staff leave. It’s not all about money. Staff need to feel valued - they are not just a commodity. They are people as well as trained experienced staff and this needs to be recognised and respected.” (senior charge nurse, 21-30 years qualified)