Ministerial Scottish Nursing and Midwifery Taskforce: report and recommended actions

2. The recommended actions

1. Work environments and working conditions

Outcome:

Employers have ensured that the conditions are in place for staff to maintain their own wellbeing by creating a working environment that adequately balances the needs of staff with the needs of the people they care for.

Extracts of what we heard:

From the Listening Project:

"Managing my wellbeing should be about me being able to do the job in the time I’m given to do it. It’s about being respected to do my job, being able to take a break and getting to go home on time. It’s simple things for me.”

From the Wellbeing subgroup discussions:

• The roles that nurses and midwives have make it more likely that they experience trauma and difficult situations at work.
• Staffing levels that do not allow breaks to be taken without impacting patient care can have a direct impact on staff health and wellbeing.

What action will be taken?

1. Employers must have appropriate staffing levels and the systems or mechanisms in place so staff are able to take contractual and statutory breaks to which they are entitled. This will include a review of the mechanisms by which breaks are effected (such as rota design and associated workforce planning tools).

2. The Scottish Government will develop mechanisms/a toolkit to ensure staff have all their essential needs met whilst at work. This will consider core aspects of need such as physical needs, physical safety, emotional safety and psychological safety.

2. Flexibility and work-life balance policies

Outcome:

Staff are enabled to have a work-life balance and a working pattern that promotes their wellbeing.

Extracts of what we heard:

From the Listening Project:

"The service needs are changing and it’s about getting managers to align with work life balance and flexible working policies being applied equally and not just to those with children. Work life balance just isn’t there now.”

From the Attraction subgroup discussions:

• Having flexible working patterns and shifts support retention
• Despite having a flexible working policy within NHS Scotland, implementation of the policy is inconsistent and weighted too strongly to local manager discretion.

What action will be taken?

3. At a national level, the Scottish Government, NHS employers and trade unions and professional organisations will review and update the definition of what flexible working means in the context of nursing and midwifery rostered environments. Following this review, flexible working practices will be promoted and implemented for both nursing and midwifery professions to ensure flexible options for staff in all roles.

4. The Scottish Government, NHS employers and trade unions and professional organisations will develop national rostering and e-rostering guidance and training to ensure it promotes a culture of flexibility and shared decision making, including team- based rostering to improve the work life balance of nursing and midwifery staff.

5. The Scottish Government, NHS employers and trade unions and professional organisations will systematically identify effective approaches to team-based rostering and give support for progressive implementation across the whole system, to promote a culture that embraces flexibility and work life balance. The review should include (a) establish what shift patterns and rota designs and on call provisions are currently used and to what extent and (b) understand the impact on staff wellbeing and safe and effective care, in order to identify if changes to shift patterns and rota and rota designs and on call provisions for nurses and midwives are necessary.

3. Career opportunities and access to education

Outcome 1:

Staff are supported to develop their skills and knowledge to support their career progress and choice.

Extracts of what we heard:

From the Listening Project:

"The job is so varied. You need to be able to get the knowledge and skills to adapt, but there is a lot of potential to develop and gain new skills to be able to go into different fields.”

From the Education and Development subgroup discussions:

• Widening participation in building a more sustainable workforce that mirrors the population that it serves.
• Offering progression and career development supports retention and can support local/regional workforce needs to be met.

What action will be taken?

6. The Scottish Government will explore with relevant partners and stakeholders, including regulators, the benefits and challenges of introducing regulation and standardised education in Scotland for nursing support worker roles. This will include considering all the available evidence regarding substitution, deployment, scope of role, increasing widening participation and suitable education programs that can enable progression to the registered nurse role.

7. NHS Education for Scotland (NES) with relevant stakeholders will review the education of maternity care assistants with the aim of understanding the potential benefits and challenges of standardised education, aligned with the level 2-4 Maternity & Neonatal Education & Development framework to increase widening participation and suitable education programs that can enable progression to earn as you learn models for midwifery education.

8. The Scottish Government with relevant partners and stakeholders will commission a comprehensive review of practice learning to:

• identify potential gaps in education provision, supervision, and IT infrastructures.
• understand the future requirements of pre- and post-registration learners, and educators aligning where appropriate with the national NMC review of practice learning and the Nurses, Midwives, and Allied Health Professionals (NMAHP) framework.
• identify gaps and the actions required to enable new learning routes, learning opportunities and CPD to be effective.
• ensure capacity, capability and opportunity within the system including options such as regional approaches to placement provision.

9. The Scottish Government will work with relevant partners and key stakeholders such as Higher Education Institutions, NHS Boards, Scottish Funding Council, Scottish Qualifications Authority (SQA) and others to develop alternative sustainable pre-registration degree education delivery and funding models that will lead to NMC approved programmes for nursing and midwifery that are structured in a more contemporary and progressive way.

This will include:

• blended and distance learning, with these programmes becoming available.
• as a priority these developments will focus on hard to recruit fields and respond to the demographic and regional challenges across Scotland for midwifery and nursing.

10. NES and employers will embed the refreshed NMAHP career framework as a tool to enable a structured approach to staff learning and development, including career planning conversations, across all four pillars.

11. Employers will ensure leadership, finance, educational programmes, and processes are in place and visible to support all nursing and midwifery learners, levels 2-9, to access relevant education provision to develop their individual career aspirations.

12. NES with relevant partners will address where there are gaps in education provision.

13. In collaboration with the Chief Nursing Officer (CNO) Research Advisory Group, and with cognisance of their recent work, agree the development of a structured approach to integrated clinical, academic and research appointments with clearer career pathways and job descriptions including clinical academic roles. This work should consider all drivers, include funding mechanisms, to bridge the gap in HEI/ Board salaries and to enable expansion of opportunities for staff to be supported to develop at MSc level and beyond. 21

3. Career opportunities and access to education

Outcome 2:

Nursing and midwifery staff are supported and encouraged to be involved in technological innovation to ensure that nursing and midwifery priorities are considered in the conception, design and implementation.

Extracts of what we heard:

From the Listening Project:

"Nurses don’t get any say in new systems that come out. We must figure it out alone and then are pressured to teach students.”

From the Attraction subgroup discussions:

• There is a need for strengthening digital literacy, and to understand the opportunities available to nurses and midwives to be involved in digital expansion.
• Having nurses and midwives involved in decisions about digital innovation and to understand if systems will work for them can no longer be an afterthought.

What action will be taken?

14. The Scottish Government will conduct a mapping exercise of the current digital landscape and will act on the findings to come up with areas for improvement around the opportunities for nursing and midwifery staff to be involved in digital transformation.

4. Manageable workload and safe staffing

Outcome 1:

Staff are engaged in the setting of staffing levels and skill mix that will reflect international evidence to enable the consistent delivery of high-quality person-centred care in an environment that promotes the wellbeing of staff.

Extracts of what we heard:

From the Listening Project:

"We are being threatened with a new system in the community, there’s different systems for different parts and depends on the GP practices etc. I have three systems to input information for diabetic reviews and then I have to write it all out again in a fourth system that repeats everything.”

From the Wellbeing and Attraction subgroups discussions:

• Duplication of paperwork and data entry required to support clinical care are time-consuming and affect the amount of time staff spend away from direct patient care.
• The risks of increased workload are that this can lead to burnout, compassion fatigue, increased incidence of poor behaviours and poor working cultures.

What action will be taken?

15. The Scottish Government will commission a review of data inputting and paperwork requirements within all nursing and midwifery roles to establish which:

1) are duplication of other inputs and requirements and

2) are non-essential either legally or for the purposes of patient safety. It will identify which ones can be removed

As part of the review, to reduce the administrative burden on nurses and midwives it will consider the effectiveness of current business systems and administrative processes and the Scottish Government will act on the findings to allow nurses and midwives to focus their time on direct clinical patient care.

16. The Scottish Government will review the predicted absence allowance in the staffing level tools used by NHS Scotland to ensure it is fully reflective of the non- clinical aspects of nursing and midwifery roles and realistic levels of absence; where the relevant duties under the Health and Social Care (Staffing) (Scotland) Act 2019 apply and applied in a consistent manner across NHS Scotland. This will support employers in meeting their duties under this Act. Where the Act does not apply to encourage adoption of this approach as best practice.

17. The Scottish Government will give consideration for future-proofing, centrally led system commissioning for interconnected communication across healthcare in Scotland.

4. Manageable workload and safe staffing

Outcome 2:

Employers are taking active steps to reduce the frequency of staff moves and where those take place that they are carried out ensuring staff are suitably supported to work within their knowledge, skills and experience and minimise impact on patient safety.

Extracts of what we heard:

From the Listening Project:

"When staff are moved, it’s not creating a safe environment, on paper it looks safe but it’s not. The NMC says you should be working within your skills, but when you say that they threaten you with NMC registration, ‘you’re a registered nurse’.”

From the Attraction subgroup discussions:

• The subgroup acknowledged the feedback from the Listening Project that staff being moved is necessary to mitigate risk and make areas safe, therefore discussions focused on how to manage staff moves in the safest way and reduce the frequency and anxiety for staff.

What action will be taken?

18. Employers will put in place a fair, consistent and transparent process to deciding which staff are moved to other areas based on their skills, knowledge and experience.

19. When staff are moved, the receiving area will give an adequate handover, orientation and resources to undertake role to ensure that patient and service user outcomes and staff wellbeing are not compromised.

20. When staff are given temporary responsibility for additional cases, employers will put in place a clear process of prioritisation based on dynamic risk assessment and identified mitigations to ensure workload remains manageable.

21. Employers will ensure a clear route of escalation is available to staff members who are moved and/or given additional temporary responsibility and feel that client/patient safety and outcomes are negatively impacted as a result, or who consequently feel unable to provide safe client/patient care.

5. Productive working relationships

Extracts of what we heard:

From the Listening Project:

"It’s hard for people to bring things up – I said a comment and it went back to my Head of Department. No one feels safe to talk out or whistleblow.”

From the Culture and Leadership subgroup discussions:

• The subgroup agreed that all nurses and midwives in all settings will work within a psychologically safe and supportive environment.

What action will be taken?

22. Building on existing good practice and evidence and through collaborative design, the Scottish Government, partners and stakeholders will develop a culture assessment tool for all teams to use in a psychologically safe way, across all health and care settings.

23. Employers will test and refine the culture assessment tool with nursing and midwifery teams.

24. Employers will implement the tool across multi-disciplinary teams to develop a consistent approach to improve organisational culture at a local level.

25. The Scottish Government, partners and stakeholders will develop a pathway to enable teams to:

1) access appropriate support for the assessment process, and

2) access support to implement required improvements.

26. Employers will ensure that nurses and midwives are fully supported and have appropriate opportunities to reflect and analyse traumatic and difficult situations they have experienced through responsive and well publicised local support channels.

27. The Scottish Government will explore a consistent approach to capturing information to allow for a better understanding of why nurses and midwives choose to leave their professions.

6. Professional autonomy and participation in decision making

Outcome:

Employers have structures in place that support shared decision making and encourage staff to participate in collaborative approaches to local and national decision making.

Extracts of what we heard:

From the Listening Project:

"Charge nurses used to run the ward, but control has been taken away. Decisions are being made without clinical and human aspects being taken into consideration. We need to go back to having supporting leaders at clinical level. The authority doesn’t match the managers.”

From the Culture and Leadership subgroup discussions:

• Enabling a person-centred culture within healthcare is crucial and results in workplace cultures that places the beliefs and values of service users at the centre of decision-making and creates the context for practitioners to do this effectively.

What action will be taken?

28. The Scottish Government, partners and stakeholders will ensure nurses and midwives can access sustainable and progressive opportunities to influence policy, practice, national and local strategy to achieve change.

29. The Scottish Government, partners and stakeholders will enable practicing nurses and midwives to participate in leadership teams across all settings to allow direct input to strategy, decision making and planning.

30. Employers, the Scottish Government, and leadership will support staff to act with autonomy, within their scope of practice, maximising their knowledge, skills and competence to influence and participate in local and national decision making on all issues that impact on their effectiveness.

7. Responsive management with supervision and mentoring

Outcome:

Employers will ensure that staff are encouraged by supportive leaders who have undertaken training and understand the qualities required for the role.

Extracts of what we heard:

From the Listening Project:

"We should feel comfortable with the processes in place. I took on my job knowing I want to see a difference in my work environment, I want those above me to want to do the same. They should know their job and role and that respect works both ways. They need to motivate us to continue downwards. I think it is changing but takes time.’’

From Culture and Leadership and Wellbeing subgroup discussions:

• Evidence shows there is a clear link between supportive, compassionate leadership and quality of care.
• Staff need time and space for peer support and reflective practice to help frontline staff manage moral injury and the pressures of the role. This will also improve patient care and outcomes.

What action will be taken?

31. Organisations and employers will commit to sustaining compassionate leadership, which evidence shows must be a critical component of every nurse and midwife’s role.

32. The Scottish Government, partners and stakeholders will support employers to establish sustainable leadership learning and development pathways and support NMW leadership development from the beginning of career across all healthcare settings.

33. Employers will promote development of leadership capacity and capability, and a talent management and succession planning approach covering all roles.

What action will be taken?

34. NES and employers will ensure a safe and supportive environment is in place in all health and care settings which empowers all nurses and midwives to develop and demonstrate compassionate leadership skills. Establish and implement robust processes to ensure staff can access and develop their leadership skills that build on existing policy and guidance.

35. An employer commitment for nursing and midwifery staff to have protected time for a model of supervision which meets the individual’s needs.

This should include (but is not limited to)

• restorative supervision,
• peer support, and
• reflective practice.

The model should incorporate provision for this to be in a safe space and at a time that is right for them; particularly following traumatic events.

8. Attraction: education

Outcome:

Nursing and midwifery careers are attractive, flexible and accessible for new entrants and existing staff.

Extracts of what we heard:

From the Listening Project:

"We need paid employment routes in, particularly to attract second career individuals.”

"I thought about it [applying for the nursing programme] for years, but caring for a family member at end of life was the push I needed.”

From the Education and Development, and Attraction subgroup discussions:

• Undergraduate entry programmes are just one route into these critical professions, and alternative routes will increase the workforce.
• The realities of being a nurse or midwife and what the career offers and entails need to be better promoted to the public.

What action will be taken?

36. The Scottish Government with relevant partners and stakeholders will build a sustainable nursing and midwifery workforce that supports and maximises existing pre and post registration programmes. Integral to this will be the development of sustainable alternative entry routes into nursing and midwifery, including part-time routes, earn as you learn, apprenticeship models and fast track routes from relevant degree-educated pools.

37. The Scottish Government with relevant partners and stakeholders will develop new entry routes with dedicated funding available to support them. This should prioritise adding to, and not replacing, traditional undergraduate routes.

38. The Scottish Government with relevant partners and stakeholders will ensure continued widening participation and that the demographic of the future nursing and midwifery workforce mirrors the population and communities it serves.

39. Widening participation must therefore go beyond SIMD (Scottish Index of Multiple Deprivation), be diverse and inclusive and respond to remote and rural needs.

8. Attraction: marketing

Extracts of what we heard:

From the Listening Project:

"If the media stops making the professions look unattractive, we might actually be able to get somewhere.”

From the Attraction subgroup discussions:

• The need to raise awareness of Nursing and Midwifery careers, promoting routes into employment, and marketing of NHS Scotland as a place to work are crucial to sustaining the workforce in the future.
• challenge perceptions of health and social care careers.

What action will be taken?

40. The Scottish Government will commission research and labour market analysis that identifies current dynamics and trends in levels of interest in nursing and midwifery careers, taking account of regional variations and any differences between fields of nursing and professions. This work will be used to identify how any future marketing activity should be shaped and targeted.

41. The Scottish Government will commission evidence-based and evaluated career marketing activity that accurately represents and promotes the roles and range of career opportunities that reflect the key pillars of clinical practice, leadership, research and education to attract and retain a diverse range of talent in nursing and midwifery.

42. The Scottish Government will work with relevant partners and stakeholders to ensure nurses and midwives are supported and encouraged to share their passion for their role and career with others, to support attraction and retention, based on their own experience of the challenges and opportunities.

43. The Scottish Government will work with relevant partners and stakeholders to ensure the consistent, sustainable provision of a range of taster schemes across health and social care that enable people from various backgrounds to experience nursing & midwifery and, on completion, participants are guided and supported to access careers in health & social care.

44. The Scottish Government will identify the barriers and enablers to attracting a diverse range of suitable candidates and develop a costed action plan to address barriers. This would include a review of the package of student financial support to ensure that nursing and midwifery students receive the right support to complete their studies.