Nursing 2030 vision

3 Nursing 2030 Vision

This chapter describes the Nursing 2030 Vision, setting out where the nursing community in Scotland is currently and where we are going as we move towards 2030.

Three key themes have emerged for the Vision:

• personalising care
• preparing nurses for future needs and roles
• supporting nurses.

The themes have arisen from the work of the engagement process, the direction of travel for health and social care policy in Scotland, and national and international evidence. While they by no means represent the whole picture on what needs to happen to nursing as we move towards 2030, they help to focus our thinking as we set out the Vision to prepare nurses to meet the population's needs now and in the future.

Actions around the themes will be taken forward through our action plan, with national oversight.

Personalising Care

Personalised care is about providers and recipients of care being equal partners. It is about moving away from the notion of nurses 'doing for' people towards the idea of 'working with' people, finding out what is important to them then using all their skills and experience to help them achieve their goals.

Personalised care calls for high degrees of technical and professional competence, but also the ability to understand what people are communicating, identify sources and resources locally and further afield that might help, work across professions and agencies in common cause, and ensure that the system works to the needs of the person, and not the other way round.

Promoting caring and compassion

The importance of caring and compassion in nursing has been stated many times. We make no apology for re-stating it here.

The engagement process for the Vision revealed that nurses, students and stakeholders hold care, professionalism and compassion in high esteem. Compassion, in particular, is considered a fundamental attribute of high-quality, personalised, rights-based care that maintains and protects patients' dignity, autonomy and choice. When combined with technical competence, critical thinking and decision-making skills, compassion provides the power behind the attitudes, values and behaviours that typify personalised care at its best.

Care and compassion are easy to see in practice, but difficult to define in words. What is clear, though, is that they mean different things to different people - what may seem caring and compassionate to one person might seem patronising or even intrusive to another.

Care and compassion, as with all things in nursing, should be tailored to the needs of the person. This will be the cornerstone of nursing as we travel towards 2030 - a personalised, rights-based service embedded within a caring and compassionate professional relationship with individuals and communities.

As we move towards 2030, all nurses will be practising to this ethos, working with patients and communities across the life-course, supporting them to make the decisions to enable them to live longer, healthier lives, helping them through periods of acute ill health or to manage long-term conditions, tackling social isolation and supporting people to engage with their communities in ways that are meaningful to them, and preparing them for a peaceful and dignified death.

It is characterised by an understanding that people are the focus and beneficiaries of all nursing endeavour, and that nurses are willing to advocate on their behalf to promote and protect their health and wellbeing. And it reflects a long-held nursing approach that focuses not only on the immediate perceived problem, but also takes into account the person's wider physical, psychological, social, family and community life to make a real and lasting difference to their health and wellbeing.

Taking technology-enabled care forward

This approach will be enhanced, but not replaced, by the use of technology, both existing and still to be developed.

It seems likely that as we move towards 2030, the impact of technology on health and social care will be growing. Many patients may well be accessing most of their treatment programmes at home through remote technologies, including consultations and discussions with professionals over video links or other communication technologies rather than face to face.

We need to ensure nurses are prepared to be comfortable in increasingly technological environments, with the technical and communication skills they need to support patients and enable their self-management potential. Measures to promote nurses' competence and confidence in this vital area of practice, including specific activity to embed technological competence in undergraduate nursing curricula, will be set out in our action plan.

Nursing has always responded positively to technological change, being quick to grasp the potential technology offers to support patients to recover and live well with their conditions. We have seen many advances in the delivery of health and social care through technological means in recent years, with nurses frequently in the forefront of pioneering e-health and telehealth initiatives.

We must be clear, though, that while technology offers a tremendous adjunct to nursing care, it can never replace nursing care - it can never supplant the human relationships at the heart of nursing, or the caring and compassionate ethos of nursing that means so much to patients, families and communities.

Preparing Nurses for Future Needs and Roles

This is fundamental to achieving the Nursing 2030 Vision. It is about how competent and skilled nurses can take on new ways of working to enable them to perform in a wide range of settings with many different colleagues and teams, while retaining a central focus on personalised, compassionate, rights-based care. And it is also about ensuring the right number and quality of nurses are being prepared with the right competence and attributes to assume their roles in the workforce with confidence.

Nursing is an incredibly wide and diverse profession that offers many career options. It takes place in a huge range of settings (including hospitals, care homes, people's homes, schools, GP practices, prisons, workplaces, and education and research institutions), involves contributions to health, social care, independent and voluntary services, and delivers services to people with health and wellbeing issues affecting their physical, mental, emotional and social status across the life-course.

This diversity and variety is likely to grow as we move towards 2030, as people's needs and the settings and sectors in which care is delivered evolve. Nurses will require the right preparation, supervision and support to be confident in taking advantage of the transformed roles that will be in place, and will need to be educated and prepared in the right numbers to meet population needs.

Securing nurses for the future

There is a clear and consistent message developing from current research that when registered nurse staffing levels fall, patient safety and outcomes decrease, and patient mortality increases. ^[3] A number of measures are in place to secure the current and future nursing workforce in Scotland, including our ongoing commitment to supporting and expanding the graduate workforce and retaining existing nurses across the health and care sectors. At the time of writing, the Health (Staffing Levels) Scotland Bill ^[4] was undergoing national consultation.

Scotland has seen successive increases in student nurse intakes in recent years. This is a very healthy situation that demonstrates nursing's attraction as a career option and augurs well for ensuring a future nursing workforce for Scotland to meet population needs. Small decreases in applications for undergraduate nursing programmes have been seen recently, however, particularly among men. The decrease is much smaller in Scotland than in other comparable countries, but is nevertheless concerning.

We know that nursing programmes are competing against many other attractive options for students who have the aspiration and aptitude to pursue nursing careers. So we need to take action now to ensure there are no detrimental repercussions for future nurse staffing levels.

A review into widening access to nursing education and careers has been launched in Scotland as part of this Vision to identify best practice and barriers to entering the profession. The Commission's recommendations will play a big part in determining approaches to maintaining and improving access - and consequently ensuring an ongoing and sustainable supply of nurses - as we move towards 2030.

The engagement process for developing the Vision suggested that some potential recruits to nursing may be harbouring false or outdated notions of what being a nurse means. They perhaps do not fully realise the extent of the role, the diversity of activity that constitutes nursing, and the vast range of settings in which nursing takes place.

Nor, perhaps, do they fully understand the academic rigour of nursing programmes, the unique opportunities offered by clinical placements to gain competence in nursing in different environments and with different patient groups, or the academic, professional and personal support offered by university and clinical staff.

They may not even realise that the bursary system for nursing students is being retained in Scotland, alongside other measures that help us attract and retain high-calibre students from across society who reflect Scotland's cultural and socioeconomic diversity.

Efforts are needed to modernise the public's perceptions of nursing - who nurses are, what they do and where they work. This will not only help to ensure the public is fully informed about, and engaged with, the benefits nurses can bring them, but also highlight the attractiveness of nursing as a career to potential students and, indeed, nurses who have not been practising for some time but would be interested in re-entering the profession. This is an area that will be explored further with stakeholders with a view to setting out concrete actions.

As we move forward, we also need to ensure nurses are educated about, and skilled in, recognising issues around nurse staffing levels and presenting evidence-based cases to ensure we have the right number of staff.

Working differently

It is vital that we continue to take steps to ensure nurses are prepared to provide the flexible and effective responses the population needs now and in the future. We do this by looking at the roles nurses currently perform and modernising them for the next decade and beyond.

Work on this has already started through, for example, the Transforming Roles programme, which aims to provide strategic oversight, direction and governance to:

• develop and transform roles to meet the current and future needs of Scotland's health and care system
• ensure nationally consistent, sustainable and progressive roles, education and career pathways.

It involves nurses not only working in different settings with different teams, but also working in different ways - being prepared to break down rigid role demarcations to benefit their patients, working in genuine partnerships with informal carers, the voluntary sector and others, providing services wherever people and communities can be accessed, and embracing the challenges of a dynamic and shifting health and social care environment with flexibility and imagination.

Our efforts through Transforming Roles and other initiatives are aimed at ensuring nurses have the right educational and personal support to enable them to assume these transformed roles with confidence and competence.

The new standards for nursing education, to be published by the Nursing & Midwifery Council in 2018, seem likely to propose a shift in expectations of what registrants can deliver. We must remain agile in responding to the standards and ensure they are reflected in how students are prepared for work as registered nurses.

Promoting health and wellbeing, and tackling inequalities

'Traditional' perceptions of nursing, which depict nurses as being focused primarily on ill health, working with others to 'sort' the immediate problem without regard to what caused it in the first place and what factors make it likely to recur in the future, are long out of date.

Nursing today still has a focus on supporting people through periods of acute ill health in hospital and in the community. But more and more it is also about prevention, addressing wider issues around promoting health and wellbeing, tackling complex social circumstances that have resulted in persistent health inequalities, and working to ensure parity of esteem between physical and mental health care.

Providing nursing care is about much more than dealing with the acute episode. The unique relationship between nurses and those they care for enables nurses to see people in the round, how they live their lives, the environments in which they live, the lifestyle elements that might be supporting or harming their health, and the obstacles they face as individuals and communities in accessing the factors that promote health and wellbeing. Nurses' proximity to people and the places in which they live, work, study and socialise puts them in a prime position to make a real impact in this area.

Informed, engaged and committed nurses throughout the country are working with individuals and communities to tackle the issues that harm health and wellbeing and advocating for change in social and economic structures to enhance people's chances of living healthier lives. They are developing sensitivities to issues such as stigma and discrimination and working with voluntary groups and others to challenge it whenever and wherever it emerges.

This focus will become more commonly embedded in nursing practice as we move towards 2030, because the evidence of nursing having impacts in these areas, which are so important to the people of Scotland now and in the future, is growing. Nurses working with people with learning disabilities provide a particular example, leading the way in showing how efforts to promote health and wellbeing and tackle inequalities make real differences to people's lives. As a profession, we need to recognise, refine and reinforce our contribution in these areas more explicitly, gathering evidence of impact and developing our offer to improve people's outcomes and experiences.

Enhancing leadership

Nurses are already leading many national and local initiatives at strategic and operational levels. This will increase as we move towards 2030. More and more, nurses will be taking the lead on:

• national initiatives, influencing and driving transformational change in the way services are designed and delivered
• local-level service redesign, working with communities and partners to make things better for the population
• individual episodes and packages of care, working with others to assess people's needs, make plans, deliver or supervise care delivery, and evaluate outcomes.

The last of these points - nurses leading on individual episodes and packages of care - has particular relevance for nurses and the population.

It is much more likely as we move through the next decade that for some patients, entire episodes of care, or specific elements of care packages, will be managed by nurses and their teams. This is a profound change not just for nurses, but also for the population, who may be accustomed to having all aspects of their care overseen by a doctor.

Many nurses in Scotland have been developing their roles over recent years, acquiring skills, expertise, experience and confidence in specific areas of practice to enable them to assess, plan, deliver and evaluate entire episodes of care for individuals and groups of patients. The emerging evidence suggests that not only are patients benefiting from nurse-led services, but services are too, with colleagues in the multidisciplinary team able to focus their energies on specific areas of expertise as a result.

As we saw in the Working differently section above, work is already underway through the Transforming Roles programme to put in place the infrastructure to ensure nurses have the skills they will require to meet people's needs as we move towards 2030. Transforming Roles includes a focus on advanced nursing practice that aims not only to develop nursing leadership for the future, but also expand nursing practice and promote research, education and development.

We will continue to act to ensure nurses have the right preparation and ongoing support to assume the enhanced roles we need for the future, and that the public understands the rationale and benefits of nurse-led care.

Supporting Nurses

The engagement process for the Vision revealed that nurses take great pride in what they do, but are facing challenges in their day-to-day lives that may be hindering their progression.

Some of these challenges are around accessing the right education and professional development activity to prepare and support them for their roles, and some are about maintaining their own health and wellbeing in the face of the stressors they experience.

This not only affects today's nurses, but may also impact on future recruitment. As we move towards 2030, it is vital that we identify these challenges and, wherever possible, take steps to address them.

Encouraging education and development

All students exiting nursing pre-registration programmes in Scotland do so with a minimum of a bachelor's degree. We are committed to maintaining this all-graduate nursing workforce.

Some stakeholders in the engagement process questioned the need for nurses to be graduates. It is certainly the case that non-graduate nurses provide high standards of care. They play a key role in the wider nursing team and are hugely valued team members.

The evidence that having a graduate workforce leads not only to better patient outcomes, but also to reduced patient mortality, is nevertheless compelling. ^[3] And as we move towards 2030, we expect the benefits of the all-graduate nursing workforce in Scotland to become more and more evident to the population.

Once graduated, nurses must have a clear and exciting career trajectory before them, supported by the right education and development as they progress. We have in Scotland national career frameworks setting out the routes nurses can take to reach their goals, and these will continue to be developed and refined to ensure they reflect current practice and future needs.

Scotland has a vibrant nursing research community that makes a significant contribution to generating the evidence base for nursing practice. Research will be further supported by promoting partnerships between practitioners and researchers to expand the evidence base for high-quality and effective practice.

Promoting nurses' health and wellbeing

Nurses of today will have longer careers than their predecessors. As 2030 approaches, working to age 70 before retiring is likely to be the norm for many citizens.

Older age does not necessarily mean poorer health, but there is a natural and gradual decrease in fitness as we age. Research into older nurses at work shows they can struggle with the physical and psychological demands, and that this can be exacerbated by, for example, working patterns. ^{[5], [6]} While little research has been done on the health or economic impacts of shift-working in nursing, it has been reported that nurses working for 12 hours or longer are more likely to report reduced efficiency and effectiveness, leading to poor-quality care, poor patient safety and more care left undone. ^[7]

The need to put in place measures to protect and promote nurses' physical and mental health and wellbeing therefore becomes even more important.

We know from important research carried out in Scotland ^[8] that some aspects of nurses' health and wellbeing are below that of other health professionals and the general population. Some are living with physical health problems, working long hours with insufficient rest, eating an unbalanced diet and taking part in insufficient physical activity, consequently leading to overweight or obesity. Psychologically, the burden of caring over many years can affect some nurses, resulting in what has been called 'compassion fatigue'. And recent reports suggest some may be facing financial hardship, and that nurses may be more vulnerable to domestic violence. ^[9]

This is not just about nurses - all workers in health and social care are liable to experience the physical and emotional stress that nurses face. But it is a big issue for nursing, which commonly involves significant levels of physical exertion and in which prolonged direct exposure to psychologically stressful situations may be higher than for other professions.

Evidence suggests there are direct links between poor health, unhealthy behaviours, psychological stress and the environments in which nurses work. Health and social care settings can be stressful. Issues such as shift patterns affecting diet, physical activity and sleep and, as a predominantly female profession, nurses' caring responsibilities within their families are also directly relevant.

All environments in which nurses work, whether in communities, hospitals, care homes or elsewhere, are hugely influential in fostering - or inhibiting - professional practice and behaviours. Physical surroundings and availability of equipment and other resources are clearly significant, but the ambience, or 'culture', of working environments is also important.

A positive culture can support nurses to feel valued, share their experiences and insights honestly and openly, and feel liberated to develop their practice and careers. But a negative culture can make nurses feel unappreciated, deny them opportunities to have their say on matters important to them, deter them from speaking out about care standards, and persuade them just to put their heads down and 'get on with the job'.

The population will only reap the health and wellbeing benefits nursing can bring them, and nurses will only experience the opportunities their careers can offer, when nurses feel supported, empowered, enabled and valued in their places of work.

Essentially, promoting nurses' health and wellbeing is a public health issue with potentially serious implications for nurses, patients and service capacity going forward. It is a complex issue that cannot be ignored. But nor must it be addressed by uncoordinated and precipitate action. It must be investigated fully, involving all relevant stakeholders to identify the exact nature of the problems and potential sustainable solutions.

As we noted above, by 2030, graduate nurses on exit from their education programmes may be looking at careers that span 50 years or more. Together, we need to find ways to help nurses stay healthier and fitter for longer so they are enabled to have long, successful and highly satisfying careers meeting the needs of the people of Scotland.

Ensuring supervision and support

We recognise that when nurses feel valued and supported, they are empowered to work to their maximum potential. They need the opportunity to feel involved in their organisation(s), know what is going on, have a say in how services are developed, and have their views heard and respected.

That is why we have a range of mechanisms in Scotland for gauging how staff feel, identifying how they can be further supported, and acting on the issues they describe as important. We must ensure these kinds of opportunities for gathering feedback and experiences from nurses continue and expand - ultimately, the benefits are seen in improved patient care and better staff morale.

Experience suggests nurses who have access to one-to-one or group supervision in the workplace derive great value. Supervision (often (but not necessarily) called clinical supervision) provides nurses with space to reflect on and discuss aspects of their role that are motivating and inspiring them, and also those elements that are frustrating or concerning them. Nurses and their supervisors can then jointly work through how the former can be promoted and the latter addressed. Processes in place for developing and assessing students' practice are similarly highly valued.

We consider supervision to be an essential part of support for nurses. It provides them with a platform to reflect on practice, agree new approaches and decide courses of action. It also, in a role that can be highly emotionally intensive and calls for a great deal of giving of self to others, provides opportunities to turn the spotlight on the nurse and her or his needs - we know from the engagement process how much nurses treasure that opportunity. And the reflection triggered by supervision can prove helpful to nurses when seeking professional revalidation with the Nursing & Midwifery Council.

We envisage that as we move towards 2030, all nurses, regardless of grade or setting, will be receiving supervision appropriate to their roles. Our task now is to seek out how that aspiration can be achieved, working in partnership with the Nursing & Midwifery Council and others.

Demonstrating impact

We know that the vast majority of people who access nursing care in Scotland have a good experience. But we also know that for a few, the care they receive falls short of their expectations, sometimes well short. That is not acceptable.

The Vision's aspiration is that everyone has a positive experience of nursing care. All of the actions that will emerge from the Vision will be targeted on that goal.

We need to make sure we have mechanisms in place to enable patients and services to see the impact nursing makes, to be reassured when standards are high, and to be able to spot quickly when they are slipping. Such a mechanism is currently being introduced through our Excellence in Care framework.

Excellence in Care is about equipping NHS boards, clinical nursing leaders and users of services with tools to measure and improve the impact of care across a number of areas, from leadership, to provision of direct care, to record-keeping. It takes into account not only hard data, but also the perceptions of key people - patients, nurses, managers - and supports boards and teams to assess how they are performing against some well-defined measures to identify how they can improve quality. Excellence in Care is therefore a mechanism for driving continuing quality improvement in NHSScotland.

Systems of assurance and improvement like Excellence in Care help to ensure consistency of standards across Scotland without losing the essence of compassionate, personalised, rights-based care. They facilitate and empower nurses to make changes in practice that result in improved outcomes for the people they serve. And they help to reignite in nurses the passion for excellence that brought them into the profession in the first place. Our action plan will ensure such systems continue to protect the public and inspire the profession as we move towards 2030.