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Section 3: Capacity

Growing the workforce

The Delivering for Health agenda requires adequate and flexible capacity among the NMAHP workforce. It needs nurses, midwives, AHPs and their leaders to look closely at those areas of service where NMAHPs add value from the patient's perspective, and those areas where tasks and functions could equally well be carried out by other health care workers under supervision. This is particularly the case across areas such as managing long-term conditions, rehabilitation and encouraging self care, which are core elements of the Delivering for Health plan.

The National Workforce Planning Framework ( SEHD, 2005c), published in August 2005, has been developed to ensure that NHSScotland maximises the efficiency and effectiveness of its use of the workforce. It introduces a cycle for workforce planning which allows assessment of the number and type of staff required for the future, closely aligned to service, financial and education planning arrangements. It takes account of a number of factors, including service redesign and changes in education, training and regulation, which in turn will help inform national decisions on overall supply and future training numbers.

The framework will be complemented by a Model Careers Framework for NHSScotland, currently under development, which will be competency based and linked to the Scottish Credit and Qualifications Framework ( SQAet al, 2001), allowing a 'building block' approach to learning and development to be facilitated. This will ensure the recognition of all kinds of learning, including work-based learning. Links will also be made to the Knowledge and Skills Framework and to the changing needs of NHSScotland.

The Model Careers Framework for NHSScotland will:

• aim to find the best 'fit' between an organisation's needs and the individual's perspective on careers
• promote principles of consistency, proactivity, dynamism and collaboration
• meet the expectations of staff transferring across national boundaries
• support the implementation of Modernising Medical Careers (see: http://www.mmc.nhs.uk/pages/home ) and other workforce initiatives.

Promoting workforce diversity

NHSScotland must be able to draw on the widest pool of talent to deliver services. Access to employment opportunities must be widened to greater proportions of the population, with measures taken to ensure potential recruits' particular needs are addressed to enhance employment prospects. This necessarily means there can be no place for exclusive, discriminatory and prejudicial thinking in developing the NHSScotland workforce.

Tomorrow's NMAHPs

There are challenges in both attracting and retaining students to nursing, midwifery and AHP programmes, with attrition rates causing concern in some areas.

Recruitment and retention of students is a key quality issue for higher education institutions ( HEIs) and their partner NHS Boards. Continuing efforts are being made to:

• promote nursing, midwifery and the allied health professions to all parts of the community as positive, exciting career options
• properly select, educate, supervise and support students
• ensure that students feel valued and included as part of clinical teams and gain maximum support and encouragement in clinical areas
• promote non-traditional routes into pre-registration/undergraduate nursing, midwifery and AHP courses by widening the entry gate through, for instance, the Higher National Certificate ( HNC) in Health Care qualification, which allows entry into Year 2 of the pre-registration nursing programme, and the Open University work-based pre-registration nursing programme being rolled out in remote and rural parts of Scotland
• promote NHSScotland as a career option for NMAHPs from other parts of the UK
• pursue an ethical policy of recruitment of NMAHPs from overseas.

A 'Facing the Future' sub-group is currently looking at the causes of student attrition in nursing and midwifery. Work is being taken forward on pre-course preparation and student selection, mentoring and practice learning, pastoral support and the development of a code of conduct for students.

Key Message
The development of the future NMAHP workforce is the business of a partnership involving education providers and NHS Boards.

There are key issues to be addressed in pre-registration courses to ensure students are appropriately prepared to play their part in implementing the Delivering for Health agenda. This means that some of the 'givens' in the NMAHP world need to be questioned in pursuit of ensuring that pre-registration/undergraduate programmes are producing professionals who are sufficiently flexible to work across a range of environments, meet a wide variety of patient needs, promote health and encourage self care, and take on key roles within multi-disciplinary, multi-agency teams.

Pre-registration/undergraduate programmes must address the core issues that are at the heart of health care policy in Scotland, and which are also at the heart of NMAHP practice (see Box 3.1).

Box 3.1 Core issues for pe-registration/undergraduate nursing, midwifery and AHP programmes
Pre-registration/undergraduate programmes should be designed to ensure the delivery of safe and effective care to patients, families and carers and should:

• promote a caring, enabling ethos
• have a strong focus on inequalities, which should be the 'lens' through which students view their future function as professionals; understanding of inequalities will prepare students effectively to provide anticipatory care, health improvement and self-care enhancement services
• promote caring for older people as a positive and rewarding experience
• view support and protection of children and adults as a core issue relevant to the practice of every NMAHP
• promote an ethos that supports self care and self management by re-shaping or reinforcing the focus of education as one of promoting patient self care, with a particular emphasis on managing consequent patient risks
• promote a values-based model for care that is patient focused and which reflects Scottish health policy and legislation, particularly the Millan Principles underpinning the Mental Health (Care and Treatment) (Scotland) Act 2003
• promote respect for and valuing of diversity
• continue to use an education model that promotes reflection and supervision to support safe and effective practice
• promote appropriate competency frameworks, ensuring that students are competent in defined skills at set points in the programme to allow progression
• develop skills in evaluation and use of research evidence
• use all opportunities for multi-disciplinary, multi-agency education activities
• involve patients, service users, families and carers as educators in programmes through a variety of face-to-face and telecommunication means
• ensure a community focus is integral to the programme.

The Nursing & Midwifery Council ( NMC) is carrying out an ongoing review of the fitness for practice of registrants at the point of registration. The review addresses a number of key issues such as selection criteria, clinical competence and sound practice assessment processes. The 'Facing the Future' sub-group on student attrition will take account of the NMC's recommendations. Phase 1 principles, standards and guidelines have been published for implementation in 2007/08.

The Health Professions Council ( HPC) has recently pledged to carry out a review of standards of conduct, performance and ethics, describing what is expected of registrants in terms of professional behaviour. The review will be undertaken by the Conduct and Competence Committee.

Key Message
The professional education students undertake should prepare them appropriately to contribute safely and effectively to implementing core issues at the heart of health care policy in Scotland and meet the agenda set out in Delivering for Health.

Developing the workforce

Initiatives aimed at growing the workforce are under pressure from a number of factors. As Delivering for Health emphasises, the Scottish population is ageing, which has implications not only for the kinds of services that will be required in future, but also for the size of the 'pool' from which the NMAHP workforce will be drawn. Nursing, midwifery and the allied health professions are also competing for students with other university courses which offer the potential for attractive career options in future.

The Scottish Executive is committed to improving the current position on the recruitment and retention of NMAHPs across Scotland. The AHP Ministerial Implementation Group set up to take forward actions from Building on Success has addressed a wide range of recruitment and retention issues, some of which are ongoing, and a range of initiatives is being progressed under the 'Facing the Future' banner for nursing and midwifery. These aim to promote nursing, midwifery and the allied health professions as highly attractive career options and to ensure that NHSScotland has the appropriate quality and quantity of NMAHPs to meet the growing demands of local communities, for now and in the future.

NHSScotland is keen to attract NMAHPs back into the NHS. A range of return-to-practice programmes for NMAHPs has been introduced across Scotland, supported by funding from the Scottish Executive Health Department in partnership with NHS Education for Scotland. Several NHS Boards have implemented the concept of 'Health Care Academies', structured programmes aimed at attracting a diverse workforce into NHSScotland. The changing demography of Scotland suggests that approaches such as these will be increasingly important over the next few years.

An individual's first experience of working with NHSScotland is likely to have a big influence on future career plans and, ultimately, the stability of the entire workforce. To this end, the 'Flying Start NHS' programme (see Box 3.2), commissioned by the Scottish Executive and taken forward by NHS Education for Scotland, aims to help newly qualified nurses, midwives and AHPs to develop the skills they need to feel competent and confident.

Box 3.2 Flying Start NHS
Flying Start NHS has been developed as a national programme focusing on common issues for newly qualified practitioners and providing support for their first year in NHSScotland . The programme is delivered through a dedicated website supported by work-based learning and aims to support the individual's progression, build his or her confidence, and assist him or her in making choices about career development.

Work is also being progressed to implement the recommendations of the Nursing and Midwifery Workload and Workforce Planning Project ( SEHD, 2004b), and will soon begin in relation to the publication of a similar report for AHPs. Three nursing and midwifery advisors have been appointed within regional workforce planning structures, and similar plans are being considered for AHPs.

There are particular workforce issues associated with delivery of services in specialist centres, such as clinical neurosciences. Delivering for Health emphasises that maintaining the skills and competency base of clinicians in such units depends to a large degree on receiving sufficient volumes of patients. Nurses and AHPs working in specialist centres will need to ensure they have access to sufficient numbers of patients regularly to maintain and develop their clinical expertise to deliver safe and effective care. They will also need access to appropriate education, training and continuing professional development opportunities on an ongoing basis. There are similar workforce issues for midwives across the range of maternity services.

It will also be important to provide NMAHPs with ongoing support through, for example, clinical supervision based on reflective practice, personal/professional development planning, individual performance review, clinical debriefing, critical incident analysis and education and training needs analyses.

Clinical supervision is particularly important in this regard. Needs will be different in different areas, as will the relative advantages of focusing on individual or team approaches, but clinical supervision is sufficiently flexible to allow delivery through a variety of means to underpin different approaches to supporting practitioners.

There are particular challenges, and particular imperatives, in developing the workforce for people living in remote and rural areas of Scotland. Issues of staffing and providing training for NHS services in remote and rural areas are addressed by Delivering for Health. It commits to establishing a 'virtual' School of Rural Health Care to build on existing initiatives and develop world class approaches to the development and training of the rural workforce. It also pledges to bring together a group involving NHS Education for Scotland, Scottish Medical Royal Colleges, NHS Boards and other partners to:

• consider the evidence around standards of care in remote and rural areas
• consider operational issues associated with the delivery of health care in remote and rural areas, including how staffing can be assured and clinicians' skills maintained in low-volume procedures
• develop appropriate training for remote and rural practitioners
• consider how training can best be incorporated into posts in these areas.

These initiatives are likely to have significant positive impacts on the work of NMAHPs in remote and rural areas of Scotland.

Key Message
The right number of NMAHPs and support workers, with the right skills and the right support to maintain and develop their competencies, are needed to deliver the services anticipated in Delivering for Health.

Developing health care support workers' roles

As was set out in the 'Context and Culture' section of this document, caring and enablement are at the core of NMAHP practice, and traditional skills bases and values should be honoured and nurtured. This does not mean, however, that NMAHPs should be 'precious' or possessive about traditional elements of the role that can equally effectively be provided by other appropriately trained health and social care workers.

The future health care demands of the people of Scotland will require all NHSScotland staff to practice in a way that promotes maximum positive outcomes for patients and carers. This may mean releasing NMAHP time and energy for specific interventions by devolving some core functions to support workers and others.

Health care support workers, in particular, can very effectively carry out a range of skilled patient tasks following appropriate preparation and under experienced supervision. NMAHPs need to have the confidence to allow support workers to take on those tasks once competent to do so. This will call on them to further develop the effectiveness of their delegation and supervisory skills.

Re-education on nursing, midwifery and AHP roles will be required not only for NMAHPs, but also for the general public. The quality guarantee that must be offered to the people of Scotland is that all elements of the NMAHP service will continue to be delivered under the supervision of nurses, midwives and AHPs in accordance with traditional core values and standards, even when some aspects of care may not be provided directly by NMAHPs.

NMAHPs must be proactive in leading their teams to ensure high standards of care are maintained, accountability is clear, and that support staff are assisted to maximise their skills and competence. A national education and training framework for support workers is being developed and work is under way to ensure the Model Careers Framework for Scotland is relevant to support workers.

Key Message
Support workers must be valued as important members of uni-disciplinary and multi-disciplinary, multi-agency teams who have an important contribution to make.

Developing clinical careers

In recognition of the need to modernise health care careers, a UK-wide initiative to develop a consistent approach across a wide range of health professions has resulted in the development of specific career frameworks for nurses, midwives, AHPs and health care scientists. The first to be published is Modernising Nursing Careers ( DHSSPSet al, 2006), a UK-wide project chaired by the Chief Nursing Officer for England. It reflects the tremendous changes that have taken place in nursing and health care and how the nursing workforce has responded to them by setting out a modern career framework for nursing. An AHP Career Framework is also being developed at UK level.

The range of frameworks will support the concept of a patient-led NHS by improving quality and productivity and promoting team working. They complement the work of Skills for Health and wider initiatives such as Agenda for Change and the review of non-medical regulation. Scotland is a full partner in this work and will make maximum use of the reports to energise NMAHP careers in Scotland.

More generally, there are rich opportunities for NMAHPs in pursuing new roles and new posts. There is, however, a perception among NMAHPs of a lack of a defined career structure through which to map career progression over time, set aspirations and targets and guide changes in direction in response to changing service design and patient needs. This makes it more difficult for individuals to identify the experience, education and competencies they will require to pursue their careers in defined ways to meet personal and professional aspirations.

It seems very likely that the health service career frameworks NMAHPs will pursue in the future are going to be based on competency acquisition to meet defined patient needs (see discussion of the Model Careers Framework for NHSScotland currently under development, above), rather than on focusing on the needs of particular professional groups. This will call for career progression to be explored from a patient care group perspective rather than a health professional perspective. An example of how this may work in practice can be found in non-medical prescribing (see Box 3.3).

Box 3.3 Non-Medical Prescribing
Delivering for Health points out that prescribing by health professionals such as nurses, midwives, pharmacists and AHPs improves patients' access to the right level of care first time. This particular element of career progression has therefore been driven by the need to improve services for groups of patients.

The policy to extend prescribing responsibilities to non-medical professions will:

• improve the quality of service to patients without compromising patient safety
• make it easier for patients to get the medicines they need
• increase patient choice in accessing medicines
• make better use of the skills of health professionals
• contribute to the introduction of more flexible teamworking across the NHS.

Delivering for Health sets out a plan to increase by 50% the number of non-medical prescribers in Scotland by Spring 2008 through the provision of education and training programmes. The Scottish Executive Health Department will issue new guidance in response to UK legislative changes on non-medical prescribing.

A recent national audit of nurse prescribing in Scotland indicated that where independent prescribing has been most successful, a number of prerequisites are in place. Importantly, one of these is effective co-operation among prescribers from medicine, pharmacy and nursing. Mechanisms that allow clinical governance issues to be actively addressed as they arise are also important.

Key Message
NMAHPs should make the best use of their skills, knowledge and expertise to provide patients with quicker and more efficient access to medicines.

The possibility of accelerated development programmes to 'fast-track' career development of individuals with high potential will be explored, along with ways to speed up the provision of skilled individuals for hard-to-fill vacancies where they exist.

It is important to recognise, however, that careers are no longer perceived as uni-dimensional concepts in which the only direction of travel is 'up'. NMAHPs in modern services are very aware of the satisfaction gained by developing their knowledge base and acquiring new skills and competencies to deliver better services, without necessarily taking on a new role or moving to a different setting. These professionals have a key part to play in taking forward the new health policy agenda, and should be recognised for their contribution.

Modernising NMAHP roles

Nursing, midwifery and the allied health professions must contribute to the successful implementation of the new policy agenda through redesigning the workforce and maximising the unique contribution they bring to the multi-disciplinary, multi-agency team.

Delivering for Health states that one of the key elements in enhancing primary care services to deliver the services patients want and need in their own communities is the extension and development of health workers' roles. This provides myriad opportunities for nurses, midwives, AHPs and others to carve out new roles in response to patient demand and need.

The effects of working time regulations and pay modernisation within the NHS are changing fundamentally the way services are offered and the way professionals work. Pay modernisation initiatives, particularly Agenda for Change and the associated Knowledge and Skills Framework ( KSF), provide the foundation for describing and redesigning future roles in nursing, midwifery, the allied health professions and others.

Significant changes to the way the medical workforce is prepared for practice are opening doors to innovative role development opportunities and the creation of new roles for other professionals, such as nurses, midwives and AHPs. They are also driving the creation of new health practitioner roles to support the delivery of medical services, such as Anaesthesia Practitioner and Physician Assistant developments.

NHSScotland needs to look at new options and new opportunities to meet the needs of the population now and for the future. Radical thinking is called for, in particular to look at the contribution new roles or new ways of working could make.

This is an area in which NMAHPs have already been very active, with some very positive effects. Elements of confusion about role development in some areas persist, however. There is inconsistency, for instance, in the nature and scope of individual advanced practice nursing roles in Scotland, including specialist nurse and nurse practitioner roles. While excellent examples of good practice exist, some roles seem to closely follow models of traditional specialisation that may no longer fit the demands placed on nursing by the new health policy agenda. Similar instances can be found within the allied health professions.

There is increasing demand for advanced nursing skills such as those provided by advanced nurse practitioners, clinical nurse specialists and nurse consultants. A group has been set up as part of the 'Facing the Future' work stream to develop a national framework for advanced nursing practice that will help to:

• clarify the skills, competencies and capabilities of these practitioners
• explore education routes to support the roles
• provide advice about developing and sustaining such roles within the workforce.

This work will build upon the Advanced Cancer Practice Nurse Specialist Framework currently being developed. This clearly identifies that in addition to advancing the skills base for professional practice, advanced practitioners also have a key role in promoting team-working as a core element of developing sustainable services that meet patients' changing needs.

NMAHPs must continue to expand existing roles and develop new roles, but the focus must be on meeting changing patient and service needs and filling perceived gaps in service delivery.
The Framework for Developing Nursing Roles ( SEHD, 2005d) and the Framework for Role Development in the Allied Health Professions ( SEHD, 2005e) should be used to provide the rationale and to underpin the implementation of such developments (see Box 3.4). Delivering for Health has committed to ensuring that the nursing and AHP role development frameworks will support the development of new and extended roles for working in the community.

Box 3.4 Frameworks for developing roles in nursing and the allied health professions
The Framework for Developing Nursing Roles was launched alongside its sister document, Framework for Role Development in the Allied Health Professions, in July 2005. The frameworks were developed through joint working between nurses and allied health professionals. The two groups found they shared an interest and faced common issues in developing tools that would assist nurses and AHPs to realise their true potential in meeting patients' needs.

The frameworks set out the key elements nurses, AHPs and their employers will need to take into account when considering role development. Specifically, they look at:

• drivers for change, examining how role development will benefit patients
• stakeholder involvement, ensuring that all those affected by (or who can exert influence on) new roles are involved in their development
• governance issues, with needs to guarantee patient safety, professional accountability and adequate resources being uppermost
• education and training support, focusing on developing competencies to meet the demands of role development
• evaluation and planning for the future, building mechanisms to ensure ongoing development of roles.

National support and co-ordination for education to support role development will continue to be provided by NHS Education for Scotland and Skills for Health, and the recognised deficit of evidence on the effectiveness of new and developed roles needs to be remedied.

Central to all activity in role development, however, is the understanding that the key values of caring, enablement, rights-based care and promoting safe and effective patient care are the underpinning elements that set the benchmarks for role development.

Key Message
New NMAHP roles developed to meet patient and carer needs must be underpinned by a caring and enabling approach that reflects professional core values.

Continuing professional development and lifelong learning

Education is a key underpinning of career development for nurses, midwives, AHPs and support workers. Modern education is about much more than studying courses in higher and further education institutions, with the workplace becoming increasingly recognised as a core setting in which learning takes place.

There are many resources through which individual professionals can update their knowledge and skills - accessing journals, online sources, libraries and open learning centres, meeting and discussing issues with colleagues, participating in in-service training activities and learning experientially through day-to-day practice, for instance. In addition, national competency frameworks are emerging in relation to specific areas of work, and these may act as benchmarks against which staff can assess their current performance and education and training needs.

A number of organisations and resources has been introduced in recent years to support health care workers and students in keeping up-to-date with current knowledge and developing their practice in a range of subjects through the application of reliable research evidence, including:

• knowledge-sharing technologies within the NHSScotland e-Library (see Box 3.5)
• the NHS Education for Scotland website ( http://www.nes.scot.nhs.uk/ )
• the RCN Scotland Learning Zone
• the NHS Quality Improvement Scotland Practice Development Unit
• the Nursing, Midwifery and Allied Health Professions Research Unit
• the Scottish Intercollegiate Guidelines Network ( SIGN)
• Managed Knowledge Networks within managed clinical networks
• Practice Education Facilitators (see Box 3.6).

Box 3.5 Knowledge Sharing, Knowledge Management
NHS Education for Scotland has published its implementation plan, From Knowing to Doing ( NES, 2006). The aim of the plan is to integrate the acquisition of knowledge by NHS workers with the real-life, day-to-day process of delivering health and health care. The plan sets out a new model for managing knowledge which will be delivered through:

• the NHSScotland e-Library
• evolving managed knowledge networks ( MKNs)
• partnership working with NHS library services, eHealth initiatives and workforce and organisational development departments.

Implementation will be based on four inter-dependent themes:

• applying knowledge to patient care
• health inequalities and patient/public involvement
• sharing knowledge
• creating a knowledge-competent workforce.

Box 3.6 Practice Education Facilitators
As part of the commitment to improving the learning experience of NMAHP students and mentors, the Scottish Executive Health Department, NHS Education for Scotland, higher education institutions and NHS Boards have invested in the introduction of Practice Education Facilitator ( PEF) roles. These posts are designed to contribute to the clinical learning environment by providing co-ordination, facilitation and support for mentors, students and staff. Within nursing and midwifery, the emphasis has been on recruiting and retaining more students, while the emphasis in the AHPs has been building clinical placement capacity and promoting multi-professional learning environments.
PEFs are clinical staff who are committed to education and continuing professional development of students and staff, and who wish to further develop expertise in this area.
For further information, access: http://www.nes.scot.nhs.uk/nursing/Practice_Education/default.asp

Personal/professional development planning ( PDP) is the key means through which NMAHPs in NHSScotland can reflect on their education and training needs with their line managers and supervisors and also focus on organisational objectives. A significant part of the PDP process focuses on individuals' perceptions of their own education needs and how they relate to team, local, area, regional and national needs and priorities. Education and training opportunities must be made available to NMAHPs in all locations, based on an overall ethos that promotes:

• increased access to education and training opportunities
• equal opportunities for all
• recognition of the individual learning needs of people with disabilities and the implications of promoting education and training to staff from diverse social and education backgrounds
• the development of NMAHPs to their full potential
• the delivery of quality education and training.

Developing clinical/academic careers

Capacity and capability in research and development will be enhanced by NMAHPs working in partnerships with the best, regardless of their professional background. For instance, they can extend the scope of their contribution to this agenda by working in partnership with expert statisticians, psychologists, health economists, social scientists, trial managers, organisational specialists and others.

Key Message
NMAHPs should always be open to working in clinical/education partnerships with colleagues from other disciplines.

The direction of travel for the short term is to develop a model for clinical/academic careers in nursing, midwifery and the allied health professions in line with the UK Clinical Research Collaboration agenda, with the aim of increasing capacity and capability for research and development. The model will need to fit with Modernising Nursing Careers and the AHP Competence-based Career Management Framework, and be supported by the Model Careers Framework for NHS Scotland.

It is important to acknowledge, however, that the clinical and academic elements of nursing, midwifery and the allied health professions have not always steered the same course. Negative attitudes and insecurities exist among each group, having the effect of stifling innovation in role development and decreasing flexibility in integrated working practices. These are imposing unnecessary restrictions on experienced clinicians expanding their research functions and on experienced researchers developing their clinical contribution. Committed clinical and academic staff have overcome the barriers to developing innovative clinical/academic roles, but the tendency has been for this to happen despite, and not with the support of, formal professional structures.

The professions need to free themselves from restrictive attitudes and insecurities. They need to create clinical/academic roles that are genuinely integrated and which pave the way for clinicians to pursue academic work and academics to make contributions to clinical work.

Key Message
Opportunities for integrated clinical, education and research roles rely on changing the cultural context of nursing, midwifery and the allied health professions to ensure that practice, education and research are equally valued within the professions.

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