UNISON is the largest union representing workers in the public services across Scotland. We have thousands of members in the health and social care sectors and we represent nurses and other health professionals in the NHS. The UNISON Scotland Nursing Sector Committee discussed the consulation paper at its meeting on 30 November and this is our response.
1. Modernising roles and public perceptions of nursing
The work we do and nursing roles have changed significantly over the past twenty years or so. The main changes that we are experiencing now are the integration of health and social care and the provision of more services in the community rather than in hospital. Despite these changes, public perceptions of nursing can be a bit dated. To help manage expectations and prepare people for future changes, we may need to update the public about modern nursing.
a) How would you like people to think about nursing? What 3 words or phrases would you like people to associate with nursing?
We want people to value nursing appropriately – that means we need enough staff time and resources. The integration of health and social care, demographic changes which are creating ever increasing demands, plus shortages of staff and budget constraints are causing increasing pressure on nurses.
We know that patients value the caring and compassionate part of nursing as well as the professional skills we bring. However the increasing pressure we face means it will get harder to provide unless we have the time, the staff, the skills and the overall resources to care. So the phrases we would like people to associate with nursing in the future would be:
‘Time to care’
‘Skills to care’
‘Resources to care’
b) What can nursing contribute to health and well-being by 2030?
We believe that nursing can contribute experience and leadership which will contribute to health and well-being. Nursing leadership will be vital to the success of Integrated Joint Boards and Health and Social Care Partnerships in order to deliver public health and health improvements.
There is a danger that the nursing focus in health and social care may be taken away by cutbacks. The IJBs are meant to tackle health inequalities, but this requires a key place for a properly resourced and staffed school nursing service, for example.
Nursing can provide education – making a positive case for change. Nursing can be an advocate – a champion for good health. However to achieve this we will need holistic care – not just a task-driven approach.
c) Think about the good examples of care and compassion that you have seen, heard about, or demonstrated recently. What should ‘care and compassion’ look like in the context of a future nursing workforce?
We see good examples of care and compassion every single day, often outwith the narrow definitions of job descriptions or tasks. However, pressure on staffing levels and resources actually prevent and get in the way of compassion – and so compassion is often seen as ‘the extra mile’.
Care and compassion complement and support health interactions to improve patient care and outcomes. Compassionate care by nurses fills in gaps in our healthcare provision – whether it is having time for a chat or helping patients to do things they otherwise wouldn’t be able to such as going to a hairdresser. However, care and compassion need to be framed in a professional health structure.
Provision of compassion is all about having enough time and enough staff to care. We have concerns that nurses are not taking breaks and that cannot be good for nurses or patients.
We absolutely need to fit time around essential compassionate care – and not care around increasingly limited time.
2. Staff experience
The population of Scotland is, on average, living longer and there is an increasing number of older people. While many older people will enjoy better health than their predecessors, they will still have significant health needs and there will be an increasing demand for health and social care services.
We need to ensure that the nursing profession attracts and retains enough people so that we have a sufficient workforce for the future. Building resilience is key to achieving this. Although the number of qualified nurses has increased significantly, overall, we know that some roles are particularly difficult to fill and recruitment is a real issue in some geographic areas. We also recognise that more needs to be done to retain the invaluable experience of older nurses and bring nurses who are not working back into the profession.
a) How can we position nursing as a really attractive career choice for new entrants?
Nurses need to be seen to be in control of our own profession.
We need to have a career framework with clearer career progression – for both registered and non-registered staff.
Care of the elderly will be increasingly important in the future – however it is widely seen as being lower on the career spectrum – less glamorous – so we need to increase recognition and improve perception of care of elderly.
Employers need to get away from fixed views on shift work patterns and times – in order to retain older nurses and attract new people we need more flexibility in hours of work.
We need to properly fund the nursing service, and show that we value nursing by paying student nurses a salary at least at Living Wage level.
b) What do we do well and what needs to change to make all nurses feel valued and want to remain in the profession?
What do nurses do well? We cope. Just. But nurses don’t have bottomless reserves of stamina. We need to have job satisfaction – to feel that we have made a positive difference. Nurses need to feel valued by their employer, by the government and by the community.
We need sustainable employment – which means real workforce planning based on service needs. Short term austerity measures cut into this and are proving costly in the longer run.
Again – nurses need to be in control of our work, our career and our profession.
One of the main problems we see in health and social care integration is the loss of control of nursing work by nursing professionals. Nurses should control budgets which relate to clinical areas – rather than social work or other local government sectors. There are dangers in social care and social work staff doing nursing work – for example medicine distribution or administering prescriptions or dealing with catheters. Nursing needs to encourage professional solidarity. This is not a demarcation issue – we need to value key roles, and to ensure proper professional governance which values nursing.
We should have established mandatory minimum staffing levels for nursing services. These should take into consideration the impact of an ageing workforce – with added experience but less youthful capacity for physical recovery from long and hard shifts.
3. Preparing nurses for future needs and roles
NHS Scotland has one of the most skilled workforces in the world and we have a proud tradition of nurse education and training. ‘Setting the Direction’ sets out the strategic aims of the profession. Looking to the future we need to ensure that we continue to have a capable, versatile nursing workforce with transferable skills. To do this we need to ensure a continued focus on nurse education and what the best approach might be.
You may be aware that work on the NMC Review of Pre-registration Education Standards has begun and the new standards are expected to be agreed in Autumn 2017. We expect that much of what is said in our discussions on the future of nursing in Scotland will feed into the NMC Review.
The Standards set out what nurses should be able to do at the point of registration, i.e. what the public can expect from newly qualified, graduate nurses. The way we prepare our nurses at pre-registration level and the skills they develop post-registration level are interlinked. We need to provide clear and consistent career pathways for nursing with education and training running alongside that is consistent and high quality.
a) How should pre-registration training change to reflect the population needs as we move towards 2030?
We should review mentoring provision to better support pre registration nurses. There should be greater support for mentors. Mentors need built in capacity in terms of time and skills for training.
We should reintroduce clinical tutors / teachers to better support mentors and students.
Student contact time with patients should be increased. Fewer wards means more students per ward which can dilute training on placement.
There should be increased emphasis on care of elderly / dementia care and health improvement.
Learning in pre registration training should deliver all round transferable skills for nursing within the first few years. Formal links with health and social care training should only take place post registration.
b) How should post-registration training reflect these changes?
There should be opportunities to do additional cross training BUT nursing skills, experience and value must be protected.
Post registration ‘joint training’ with social care colleagues should be nurse focussed to deal with dilution of nursing profession.
We need to find ways to mentor and support newly qualified nurses who only work on the nursing bank.
c) What is needed from the clinical skills aspects of (pre and post-registration) nurse training and how could this be enhanced?
As suggested above, we believe there is a need to reintroduce clinical skills tutors and to give more hands on training and face to face patient contact.
d) How should the role of nursing evolve to reflect the population needs as we move towards 2030?
There will be an increasing number of elderly people in the population and this will mean elderly care will present increasing demands. We need to ensure that we attract enough new staff to cope with these demands.
We should equalise the profession so that there is more focus on care of elderly – and we should promote every nursing job and role as useful.
In the first two years newly qualified staff should rotate across disciplines
– this will help to build base of knowledge
– creates the team
– opens doors for knowledge and general skills
Nurses are nurses first – then specialists.
We need to value part-time work and shorter shift patterns
4. Working in health and social care teams
In the future, there will be more people with multiple conditions and more care will be provided in the community. Clinicians will need to work increasingly in teams across specialisms and be supported by better information sharing and clinical decision support systems. The clinical team will work collaboratively with social care staff, and increasingly signpost patients to third sector organisations that provide community-based support.
The healthcare we provide will be proportionate and relevant to individual patient’s needs and we will use minimally disruptive interventions. This it will be delivered by teams of professionals united by common professional values and with effective clinical leadership.
a) What role should nurses play in the context of more care being provided in the community (integrated health and social care)?
Nursing should play a prominent role in the integrated health and social care service and should be the lead role in clinical care within this context.
Nursing should be lead role in health improvement / public health.
Nurses should be in charge of budgets – controlling spending will prevent dilution of nursing role and give a final say on clinical / health promotion / public health care.
Nurse leadership is key to health promotion models (eg Buurtzorg) which seek to avoid hospital readmission – this means that we will need:
– a high value for professional nurse governance
– budget holder responsibility for clinical care
– nurses to be in high level posts in IJBs to ensure that nursing is valued, to lead on and influence the clinical role of nurses and patient impacts if care is not met.
5. Nursing practice and health promotion/public health
We know that some lifestyle choices results in too many early deaths in Scotland. The healthcare system has a key role in supporting and empowering people to live well and nurses can make a significant contribution to prevention and anticipatory care. Nurses can help people take more responsibility for their own health, support them to tackle their personal health challenges, including long term conditions, and enable them – as far as possible – to retain independence and control.
a) What role should nursing play in health promotion and public health?
Nurses should play an important role in health promotion and public health particularly in delivery but also in strategic and policy planning to prevent ill health.
We need a culture change – nursing is identified with ‘sick people’ or people who are already failed by health promotion and prevention.
We have problem of hospital beds and waiting lists – health promotion is key to addressing this. Health promotion should be reconnected into nursing – see above regarding the ‘extra mile’ and additional quality – and should be valued appropriately.
Nursing staff need time to build relationships and help deliver better health.
Nurses have role to help planning in public health for major outbreaks, reportable incidents and other issues.
b) Identify 3 things that need to change to make this possible?
1 – Nurses need time to create opportunities to positively engage in the health promotion agenda, and resources such as appropriate technology to allow for recording notes and managing
2 – Training – including adequate time off.
3 – The nursing role in health promotion and public needs to be valued by the community sector