The NHS Next Stage Review workforce report, A high qualityworkforce*, indicates that nurses will always be at the heart of shaping the patient experience and delivering care. It promotesfurther work on reaffirming the role of the nurse and also supportsthe development of metrics to measure and help improve the qualityof nursing care. So, what does this mean for the largest section of thehealthcare workforce?

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Discussion paper 3

* References to the Next Stage Review throughout this paper relate to the Department of Healths report: A high quality workforce: NHS Next Stage Review.

Fluctuations in workforce supplyand demand, coupled withchanges to policy for thenursing profession andhealthcare service delivery make workforce planning andanalysing the future role of thenurse a challenge.

Delivering the vision of the Next Stage Review (NSR) tomodernise all healthcare careerswill require the engagement ofthe whole of the NHS. This willapply whether these are clinical,administrative or support-basedroles. The process starts beforeeducation, with the need tomarket healthcare careers andclearly profile the behavioursand values the NHS needs in its future workforce.

It is vital that any new policies orframeworks support employersneeds in terms of what they wanttheir future nursing workforce tolook like and put quality at thecentre of any change.

This discussion paper has beenproduced:

to give you a summary of theemerging issues

to provoke thought anddiscussion about proposals tomodernise the nursingworkforce

to engage you in the debateand formulation of policy byasking you to respond to anumber of key questions. Thequestions may also be useful

to start debate within yourown organisations.

This paper discusses nursing ingeneral and not particularspecialisms, branches, healthvisitors or midwives. These willbe addressed as our workprogramme progresses.

BackgroundWhat does our workforcelook like now and what willit look like in the future?

The NHS in England currentlyemploys 315,410 qualifiednursing, midwifery and healthvisiting staff.

The Workforce Review Team(WRT) published theirworkforce predictions in

2Framework and the Agendafor Change pay framework.

In 2006, NHS Employerspublished an overview ofevidence related to theEmployment of registerednurses: the effects on patientoutcome and on nurseemployees. The evidenceshows that the way in whichorganisations employ nursescan directly affect patient well-being, recovery andmortality. Research on theeducational background ofnurses could show that nurses holding a Bachelordegree can have an impact on reducing mortality andfailure-to-rescue incidents.

The Dr Foster Intelligence,published in the NursingTimes in March 2009, showsthat there were lowermortality rates and shorterhospital stays in acute trustswith more nurses per bed,although it also makesreference to having thecorrect skill mix present alongthe patient pathway and howthis will ensure that patientoutcomes are improved.

What are the policy driversfor change?

We have listed below some of the policy drivers thatemployers need to workthrough when assessing whattheir future nursing workforcewill look like. It is likely therewill be more that impact on the decision-making processesand this means that solutionswill need to be flexible to adapt to future changes. TheNSR provides the vehicle for all of the changes to bedelivered and makesrecommendations of its ownaround the education andcareer pathways of nurses.

Modernising Nursing Careers

Child Health Strategy

Maternity Matters

World Class Commissioning

Transforming CommunityServices

European Working TimeDirective

In March 2009, the Commissionon the Future of Nursing andMidwifery was created. The

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October 2008, which showedthat although supply largelymeets demand, if currentcommissions are maintainedthere will be a reduction intrained nurses in the future.

We should not think of ourfuture workforce simply interms of new entrants. In2020, 85 per cent of ourworkforce will be people whoare currently employed withinthe NHS in some capacity.

The Information Centrecensus data, September 2008,shows that the number ofnursing support roles workingin the NHS in Englandincreased from 132,915 in1998 to 144,892 in 2008,although after a dip innumbers the 2008 figure iscomparable to the numberemployed in 2003. It is widelyacknowledged that theseroles will continue to exist andneed to grow in number.There are currently nonational standards ofproficiency or framework ofcompetencies for the varietyof roles that feature in Bands1 to 4 of the Career

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Commission, which reports onits findings to the Prime Ministerin March 2010, aims toinfluence how nurses andmidwives can improve thequality of care, health outcomes and experience of patients.

The current recession in the UK has not only had an impacton the commercial sector, butalso places demands on thepublic sector to demonstratesavings and efficiencies whileincreasing quality andmaintaining public confidence.The Releasing Time to Careprogramme can help employersto get value for money, inspireinnovation and empower staffto contribute to wider objectivesaround productivity andefficiency.

Areas for discussion1. Degree-level registrationfor new entrants to theprofession

After extensive consultation, theNursing and Midwifery Council(NMC) announced in September2008 that new entrants to theprofession will need to be

degree-level qualified in order to gain registration to practise.This piece of work formedphase one of the review of Pre-Registration NursingEducation (RPNE). Phase two iscurrently underway.

The decision to move to degree-level registration for newentrants to the profession willbring nursing into line withother healthcare professions inthe UK and with entry to theprofession in several othercountries in Europe andelsewhere. The stimulus for theshift to degree-level registrationis recognition of:

the increasing complexity ofthe roles that nurses have toundertake

the higher levels of autonomyand interaction with otherprofessionals, inside andoutside healthcare

a desire to attract and retainthe highest calibre recruitsinto nursing.

The NMCs decision issupported by a set of principlesfor a future framework for

pre-registration nursingeducation as a first part of theModernising Nursing Careersprogramme; these are:

minimum award of a degreefor pre-registration nursingprogramme

professional recognition onthe Register denoting the fieldof practice

nature of the programme tobe a blend of generic andfield-specific learning that hasflexible boundaries, butspecified competencies andoutcome measures linked toprogression points

length of the programme tobe a minimum of three yearswith a 50 per cent theory/practical split, includingsections of time in communityand other practice settings

stepping-on and stepping-offagreements

a period after registration formandatory preceptorship.

As a response to phase one of the consultation, employerssupported the move to

4degree-level registration for newentrants. They also highlightedthat the shift comes with anumber of issues that needemployer and educationinvolvement to implementsuccessfully, namely the contentof pre-registration nursingprogrammes.

The second phase of the review isnow underway. It focuses on thedevelopment of generic and field-specific competences theknowledge and skills that nursesneed for practice. The NMC isalso looking at developing ateaching, learning and assessmentframework, which aims toincrease opportunities for sharedlearning between students ofdifferent nursing fields and otherprofessions. The outcome of thereview will be standards ofproficiency for pre-registrationnurse education, which should bepublished by Autumn 2010.Updates on the NMC work willbe published on our website:www.nhsemployers.org

In addition to the developmentof the NMC competences andframeworks, employers want tomaintain strong relationships

with the local higher educationinstitutions that provide nursetraining courses. This will ensurethe content of the programmesinclude employers requirements,and will provide clarity on thetypes of courses and number ofstudents they will be acceptingin the future.

Review of student bursaries

The decision to move to degreeregistration for new entrantsraises some issues with thecurrent student bursary schemethat provides financial supportto those currently undertakingnursing studies. There is ananomaly in the system whichawards a non-means-testedbursary to diploma students anda means-tested bursary todegree-level students.

The NSR indicated that thefunding system needs to bereviewed and there is worktaking place to prepare optionsfor a formal consultation. ThisDepartment of Healthconsultation will run from theend of July until mid November2009. We will be seeking viewsand coordinating a responsefrom employers.

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Key questions foremployers How do you see nursing

roles within yourorganisation developingwhen all new entrants tonursing are qualified todegree level?

What does this mean for improving the quality of care? How will you measure andreport this?

What does it mean forworkforce planning andeducation commissioning?

If there are less qualifiednurses in the system, who will be providing the care?

What will the shape ofyour nursing workforcelook like?

If the shape looksdifferent, what needs tohappen to ensure asmooth transition fromwhere you are now to fiveyears in the future?

52. Embedding the practice of preceptorship

The Modernising NursingCareers programme has thegoals of creating a more flexible and competentworkforce, updating careerpathways and better preparingnurses for leadership. A keyelement of the programme,repeated in the NSR, is thecommitment to a foundationperiod of preceptorship at thestart of a newly-qualified nurses career. The NSRannounced a threefold increasein the amount currentlyinvested, to provide professionalsupport and protected time fornurses as they move intopractice for the first time, laying a solid foundation forlifelong learning.

Preceptorship combines informalone-to-one learning fromexperienced practitioners withstructured learningopportunities, some formalappraisal and recording of thecompetences and confidenceacquired. While weacknowledge that someemployers have preceptorshipprogrammes in place, given

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Key questions foremployers What should

preceptorship look like and how will it be assessedor measured?

How can you plan andresource the increase inpreceptorship for all newnurses across all areas of activity?

Does it need to beprofession-specific?

the funding commitment made in the NSR employersneed to be clear about howthey are going to develop andembed the principles of nursing preceptorship in theirorganisation.

3. Supporting roles:healthcare assistants andassistant practitioners

To support the delivery of high-quality and safe care, theNSR included a commitment toensure that staff in clinicalsupport roles are appropriately

trained and for all staff to havecareer frameworks.

The Workforce Review Team(WRT) forecasts indicate that thequalified nursing workforce willbe proportionally smaller in thefuture and therefore the role ofthe healthcare assistant andassistant practitioner becomeeven more crucial to ensuringthat patients continue to receivehigh-quality care.

In addition to the plannednursing commissions, analysissuggests that the move todegree-level registration fornursing may mean that not allstudents who currently apply for diploma courses would have the qualifications to beaccepted directly onto a degree course. This creates agap in the workforce supplychain, which employers need to consider and include inworkforce developmentplanning and business planning cycles.

It is also thought that as newgraduate nurses come onstream it is likely that theirpractice, as a whole, may shiftslightly upwards. This means

64. Access routes into nursing

To make sure that access to the nursing profession is notcompromised while maintaining high-qualitystandards of nurse education,there need to be opportunitiesto allow entrance to nursing asa second career, a maturestudent or a student who hasnot obtained the requiredacademic qualifications fordirect entry into nurseeducation. To widen access and break down some of thebarriers an all-graduateregistration profession maycreate, there needs to be arange of additional accessroutes and clear training

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that in the future more caremay need to be provided byappropriately trained anddeveloped clinical support staff.Some of these staff willprogress to a professional careeras highlighted in the Grow ourown professionals for the newNHS project. The supportingroles will not necessarily looklike they do now and will evolveto meet service needs. This willadd a different dimension to theshape of the workforce.

The step change fromemploying registered nurses and healthcare assistants tograduate nurses and assistantpractitioners at Agenda forChange band 4 needs to beassessed carefully by employers.

pathways, both for new andexisting staff. These include:

14 19 diploma

apprenticeship programme

foundation degree.

Key questions foremployers Do you have an established

assistant practitioner rolethat operates at level 4 ofthe national skillsframework?

What are the governancerisks of having a larger

proportion of theworkforce being non-regulated and howcan this be addressed?

What would a supportingrole need to look like tomeet your service needs? Is it profession-specific or generic?

Key questions foremployers How should these access

routes and trainingpathways be developed tosupport employer needs?

Should the programmes be profession-specific orcomprise genericcompetences and why?

5. Flexible career pathways

With the majority of the futureworkforce coming from withinthe NHS, employers must makesure that roles are not onlyattractive and empowering toindividuals they wish to recruitand retain, but also payattention to developmentneeds, career aspirations andflexible career pathways fortheir existing workforce. At

7the same time, employersshould be increasingly aware of the return on investment for staff training and education.

There have been a number ofchanges in recent years thathave had a direct impact on therole of the nurse, for example:

an increase in long-termconditions

the move to pathwaymanagement

care being delivered closer to home

an emphasis on self-care

a growing public healthagenda

the impact of TransformingCommunity Services on theprofession.

The role of the nurse and thewhole clinical team looksdifferent now and will continueto evolve as policy relating tothe profession changes.

The career pathway of the nurse needs to be flexible torespond to the needs of thefuture and ensure that it

attracts and retains those with the behaviours and skills needed by employers and patients.

Work is already being takenforward by the Chief NursingOfficer with Skills for Health aspart of Modernising NursingCareers to develop careerpathways for nurses. Thisincludes looking at corecompetences in level 5 postsacross all five pathways, with a particular focus on looking at progression from newregistrant to the end of the first year and then to the top end of level 5. This will demonstrate and celebrate the breadth ofpossibility at this level and tie in with work onpreceptorship. The aim is to eventually extend this work across all levels from 2 to 8 in a similar way to thechanges already achieved forallied health professionals.

Although work is underwaycentrally, employers will alsohave their own programmes tosupport the development ofadvanced practice, movement

into management and nurturingleaders. It is important thatthese local experiences arecaptured as case studies toinform any centrally developedframework.

Options for careers in clinicalacademia have also beendeveloped. The NationalInstitute for Health Research(NIHR) and the Chief NursingOfficer for England havelaunched a joint initiative for aclinical academic trainingpathway for nurses, midwivesand allied health professions.The initiative has beendeveloped in partnership with the Economic and Social Research Council (ESRC) and the HigherEducation Funding Council for England (HEFCE).

A principal objective of theinitiative is to nurture theacademic and research evidence base that will berequired to educate thegraduate nurses of the future.The first successful candidatesfrom the new fundingarrangements will take up posts from September 2009.

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6. Enhancing patientexperience

The NHS Confederation isscoping a piece of work aroundpatient experience. Thisprogramme is looking at positiveclinical outcomes, efficientprocesses, dignity andpersonalised care. The nursingworkforce has a crucial role toplay in enhancing the patientexperience but it is also notedthat it is not the soleresponsibility of those working innursing roles. As part of the NHSConfederation, NHS Employerswill be working with colleaguesto ensure the programmescomplement each other.

As well as the work beingundertaken within the NHSConfederation, the RoyalCollege of Nursing (RCN)conducted a dignity survey inFebruary 2008 which attractedresponses from more than2,000 nurses. Almost all saidthat the dignity of patients wasimportant to them as nurses,and over 80 per cent said theyfeel distressed when they areunable to give the dignified carethey know they should. Inresponse, the RCN launched a

campaign, Dignity: at the heartof everything we do, with theaim of demonstrating howmuch nurses care about thisissue and finding ways tonurture more dignified care.

Having time for dignified care iscritical, with 65 per cent ofrespondents to the RCNs surveysaying they sometimes or neverhave enough time to devote tothe dignity of patients. Pressureon staffing levels, volume ofpaperwork and lack ofleadership were all cited asorganisational obstacles todignified care.

A number of physical factorswere identified as crucial tosustaining dignity in care:

cleanliness and privacy of toilets

curtains around beds

single-sex bays in wards

gowns that protect modesty

private space for intimate careand conversations.

There is also, prima facie, anassociation between dignity of

Key questions foremployers What do you need to do

to prepare your workforcefor work outside of thehospital setting?

What are the gaps in the current careerpathway?

What can be introduced in a new career pathwaystructure to enhance staffretention?

How do you supportnurses to hone theirleadership andmanagement skills?

How will you support theclinical development ofpostgraduate nursesundertaking clinicalacademic careers?

Does your organisationhave a forum whereresearch questions aboutnursing practice can bedeveloped and refined andthen addressed by clinicalacademic nurses?

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care for patients and dignity intreatment of staff. In the case of nurses, this means beingrespected for theirprofessionalism at ward level orin other arenas of care, andhaving a voice at board levelwhere issues of dignity andquality of care are given properconsideration.

Employers should have effectivemechanisms in place to reviewpatient and staff feedback atboard level. They should alsoconsider how well the physical environment of theirwards protect and promotepatient dignity.

7. Measuring nurseperformance

The priority given to qualitywithin the NSR, and thecommitment to hold trustsaccountable, raises the importantquestion of how nursingoutcomes can best be measuredand best practice rewarded. Thekey criteria cited for nursing arecompassion, safety andeffectiveness. Indicators forsafety are already widely used,such as failure to rescue, falls,healthcare associated infection

and pressure sores. Compassionor, more appropriately, patientexperience of care andeffectiveness as the positivecontributions to well-being, aremuch harder to quantify.

Any selection of indicators andsetting of standards presentschallenges and the front runnersfor use by employers can beviewed in the 2008 NationalNursing Research Unit reportState of the art metrics fornursing: a rapid appraisal.Indicators should be measurablewith available or easily-acquireddata at reasonable cost.Otherwise, resources and energymay be distracted from theprincipal activity or providinghigh-quality care. There must beevidence that nursing contributesto changes measured by theindicator, and the indicatorsmust be recognised as significantto employers, patients andpractitioners. Also, there is a riskthat focusing on a few keyaspects of care may prejudiceoverall performance andimprovement.

Developing useful and reliableindicators of quality will require

the involvement of the nursingprofession, regulators,employers and patients.

Have your say The NHS workforce is at theheart of quality patient care andwe believe that employers mustdrive the workforce agenda.

To enable us to representemployers views and toinfluence the formulation ofpolicy and frameworks, we need to hear from you. Wehave created an onlinequestionnaire to gather yourfeedback on the key questionsposed throughout this paper. By responding to thesequestions, you are helping us to reflect your views and give a representative view on behalf of employers.

Please take the time to shareyour views atwww.nhsemployers.org/nursing and please let us knowif there are other unansweredquestions you, as an employer,feel we need to explore.

We are also asking if you are happy to be contacted

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further in relation tocontributing to the wholenursing debate or a particularsection of interest, for exampledeveloping the pre-registrationnursing curriculum or developinga framework for Agenda forChange bands 1 to 4.

NHS Employers workprogramme NHS Employers continues torepresent you, working closelywith the Department of Healthand the Nursing and MidwiferyCouncil on various policy

formulation groups. Thefeedback we gather from ouronline questionnaire will help usto ensure that we are reflectingyour views and interests.

We will keep you informed ofthe latest developments andnews through regular updates on our nursing webpages and our weekly NHSWorkforce bulletin.

We aim to gather and publish case studies onpreceptorship, training forbands 1 to 4 and metrics, which we will place on the

shared learning section of our website.

We will be using the HRdirectors network meetingslater in the year to update youon our work and we are alsolooking at holding bespokeworkshops for employers. There will also be a session onthe future of nursing at ourannual conference, Leadingworkforce thinking, inNovember 2009.

Contact us atrecruitmentandretention@nhsemployers.org

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References and further readingNHS Employers website: www.nhsemployers.org/PlanningYourWorkforce/Nursing/Pages/Nursing.aspx

A high quality workforce: NHS Next Stage Review. Department of Health, 2008www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085840

From ward to board: identifying good practice in the business of caring. Kings Fund / Burdett Trust for Nursing, 2009 www.kingsfund.org.uk/document.rm?id=8212

Royal College of Nursing, Dignity Campaign www.rcn.org.uk/newsevents/campaigns/dignity

State of the art metrics for nursing: a rapid appraisal. National Nursing Research Unit, 2008www.kcl.ac.uk/content/1/c6/04/32/19/Metricsfinalreport.pdf

Nurses in society: starting the debate. National Nursing Research Unit, 2008 www.kcl.ac.uk/content/1/c6/04/32/16/NursesinsocietyFinalreport.pdf

Confirmed principles to support a new framework of pre-registration nursing education. Nursing and Midwifery Council www.nmc-uk.org/aArticle.aspx?ArticleID=3396

Assessment of workforce priorities. Workforce Review Team, 2008 www.wrt.nhs.uk/index.php/work/specs-profs/54-nursing-midwifery

Modernising Nursing Careers, Department of Healthwww.dh.gov.uk/en/Aboutus/Chiefprofessionalofficers/Chiefnursingofficer/DH_4049335

Releasing time to care: the productive ward. NHS Institute for Innovation and Improvementwww.institute.nhs.uk/quality_and_value/productivity_series/productive_ward.html

Annual workforce census. The Information Centre for Health and Social Care www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbers/nhs-staff-1998--2008-overview

Transforming community health services. NHS Employers briefing, February 2009www.nhsemployers.org/Aboutus/Publications/Pages/TransformingCommunityHealthServices.aspx

Dr Foster reveals link between nursing levels and patient care.www.drfosterintelligence.co.uk/newsPublications/article125.asp

Grow our own professionals for the new NHS. Skills for Health, Widening Participation in LearningStrategy Unit www.wideningparticipation.nhs.uk/pages/kbdownload97d4.html?id=120

NHS Employerssupporting promoting representing

NHS Employers represents trusts in England on workforce issues and helps employers to ensurethe NHS is a place where people want to work. The NHS workforce is at the heart of qualitypatient care and we believe that employers must drive the workforce agenda. We work withemployers to reflect their views and act on their behalf in four priority areas:

pay and negotiations

recruitment and planning the workforce

healthy and productive workplaces

employment policy and practice.

NHS Employers is part of the NHS Confederation.

When you have finishedwith this briefing pleaserecycle it

Contact usFor more information on how to become involved in our work, email getinvolved@nhsemployers.org

www.nhsemployers.orgenquiries@nhsemployers.org

NHS Employers29 Bressenden PlaceLondon SW1E 5DDThis document is available in pdf format at www.nhsemployers.org/publications Published June 2009. NHS Employers 2009. This document may not be reproduced in whole or in part without permission.The NHS Confederation (Employers) Company Ltd. Registered in England. Company limited by guarantee: number 5252407

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