Nurses working harder than ever

  Three in five nurses are working in extra hours on top of their main job5.

  Half of nurses now feel under too much pressure at work5.

  More than half feel their workloads are too heavy5.

  The Audit Commission has reported that it costs £5,000 to recruit a nurse11.

  NHS employers in England spent £192 million on agency nurses, and £41 million on recruitment advertising12.

The quality of workforce data collected

  The reliability of workforce information varies considerably at trust level. It is hindered by the deficiencies of some of the computer databases which are basically payrolls with additional human resource data records. This means that some trusts, for example, are unable to separate out paediatric nurses from registered general nurses (RGNs), or enrolled nurses working at D grade from RGNs, as they may be on the same pay scales. This problem has been resolved in most cases by using occupational codes to identify such staff. In a few instances, trusts have been unable to provide accurate staff-in-post information.

  The better consortia address these issues be raising the profile of workforce planning through the running of workshops and by making senior consortia members accountable for the delivery of timely and accurate workforce plans. This gives the consortia enough time to evaluate the overall credibility of plans. In addition, the consortia commission surveys of the private sector, using projections based on past trends and the input private sector managers were willing to make on their future demand. The latter are much more guarded than their NHS colleagues about their plans, as they are concerned about commercial sensitivity.

There are a range of criticisms that can be levelled at the current arrangements for planning education and training

  They do not always relate to the annual trust plans, involving line managers in some duplication and wasted effort. Trust plans have typically been for only one year ahead, a result of the contracting regime. Trusts are now encouraged to plan further ahead, and include five year plans.

  Trusts tend to concentrate on service developments setting out the appointment of new consultants, often without estimating the impact on staff and services to support them, resulting in additional pressure on nurses and other staff. Trust plans tend to lack detail, so, for instance, they may set out the need to make savings of £3 million without setting out how such savings are to be achieved.

  The trust planning cycle is also out of step with education and training, with the former taking place in September and October and the latter occurring in April and May. This has led some consortia to seek to harmonise their planning arrangements.

  A further criticism of current planning is that it focuses on staff groups, although patient care is managed on a care group or clinical directorate basis.

  These problems are recognised in the Education and Training Planning Guidance of October 1997, which calls for workforce planning that is integral to service planning, and crosses health and social care boundaries and crosses professional and vocational boundaries.

  It may be the case that, in future, consortia move towards an approach where planning is based on care groups, such as elderly people, mental health or children's services. This will provide a substantial undertaking and will require very detailed information on staff not only by qualification but area of work. It will be particularly difficult where staff groups divide their time between a variety of care groups. For instance, RGNs might work in care of the elderly or gynaecology. In addition, comparable information would be required from other care providers.

  A natural consequence of planning by care group will be to encourage health care providers to think about extending staff roles and reducing the types of professionals and profession-specific support staff involved. This is a long term process that can only be properly addressed through shifts in the education system and changes to the curricula. The likely effect will be the development of more multi-professional post registration courses and greater support for lifelong learning and continuous professional development.

The RCN believes that national workforce planning is vital, with due attention to the multi-disciplinary needs of the health service. The following modifications are needed:

  There must be greater and more open dialogue between the consortia (who purchase education) and the universities (who provide it). It many cases relationships are still at an immature stage. Employers have only limited understanding of some cultural aspects of higher education, while universities do not always recognise employers legitimate concerns.

  Accurate workforce planning must take full account of the competition from the independent sector for nurses.

  While many of the key decision makers on education consortia are from a nursing background, there is no explicit recognition that nurses and other professionals are key to the process of planning the healthcare workforce. The RCN believes that nursing must be represented on all consortia.

  Local planning must be tempered by a UK-wide overview of supply and demand. Many nurses move across regions, and across country borders on qualification or subsequently. While there are some minimal checks and balances within England there is no UK wide perspective.

  The RCN began to predict the current shortage of registered nurses in the early 1990s, but was met with blank stares and denials by the Department of Health and employers organisations. Workforce planning decisions at local, country and UK level, and the data which underpin these, should be available for public scrutiny regularly and as a matter of course.

V.  REVIEWING THE BREADTH AND SCOPE OF NURSE EDUCATION

  During the past 20 years there have been dramatic changes, both in educational attainment of school leavers, and in the requirements for admission to universities. More than half of all entrants to higher education are now not the traditional 18 year old school leavers. For instance, the average age of a student nurse is 26. Female participation on the workforce and in higher education has expanded massively. Students want degrees, and the parents of students want their children to have degrees.

  Nurses are now amongst the few health care professionals who are not wholly prepared at first degree level. It would be surprising if this difference were not reflected in the way in which nurses perform and are viewed by others. The RCN believes that, over the next 10 years, the profession should move towards the position where pre-registration nursing education should lead to registration as a nurse and the award of a first degree. We argue that such a move is both desirable for reasons of patient care, and inevitable if nursing is to emerge once again as a desirable profession. The Government's recent emphasis on widening the entry gates to nursing, including bursaries for enrolled nurses to retrain and return to the NHS, special bursaries for existing NHS staff, such as health care assistants, to enable them to train as nurses, and more part-time pre-registration nursing and midwifery courses are particularly welcome. The RCN believes that a greater emphasis on NVQ level entry to nurse education, coupled with fast-tracking for experienced health care staff, could also give wider access to nursing as a career.

Lifelong learning

  The RCN endorses the view that quality patient care is underpinned by a process of lifelong learning.A First Class Service rightly recognises the role of lifelong learning in creating the culture needed to improve quality in the new NHS. However, it is important to highlight the distinction between lifelong learning and continuing professional development.

  Lifelong learning is not something that can simply be put in place or given to NHS staff. The RCN Institute defines lifelong learning as follows:

    "a journey throughout a person's life, during which learning occurs and knowledge, skills and attitudes are gained, as a result of both formal and informal educational opportunities and experience. Lifelong learning, for practitioners, is set within the context of their profession, their workplace and employer, their patient/client relationships and society. The learning can, therefore, be affected by these factors and can bring influence to bear on them".

Continuing professional development

  Continuing Professional Development (CPD) is set within a lifelong learning approach but is more specific and purposeful. The values on which it is based include:

—  equality of opportunity

—  the importance of self-fulfilment

—  freedom to learn

—  responsibility for self

—  valuing what other learners can teach

—  an enquiring mind, able to think critically

—  facilitation . . . rather than dictation.

  Access to CPD is a pre-requisite for all health professionals and should be available on an equitable basis. Currently this is not the case. Nurses frequently have to fund their own CPD activity and participate in their free time. A 1997 Institute of Employment Studies7 survey of how nurses meet their Post Registration and Practice (PREP) requirements indicated that only 35 per cent of NHS staff were allowed time off work for private study and 32 per cent received financial support for study.

  The RCN sees the lack of a national financial framework to underpin CPD for nurses is a major barrier to quality improvement throughout the NHS. Without this commitment, there is a danger of the Government promoting CPD rhetoric rather than reality.

 REFERENCES

  1 Working Together: securing a quality workforce for the NHS launched by Health Minister Alan Milburn at the Association of Healthcare Human Resource Management conference, 23 September 1998

  2 The New NHS: Modern, Dependable. HMSO Cm 3870. Dec. 1997

Designed to Care: Renewing the NHS in Scotland. Scottish Office Department of Health HMSO Cm 3811. December 1997

NHS Wales: Putting patients first. Welsh Office. HMSO Cm 3841. January 1998.

Fit for the future: A consultation document on the Government's proposals for the future of the Health and Personal Social Services in Northern Ireland. DHSS, Northern Ireland. May 1998.

Our Healthier Nation Cm 3852

A First Class Service: Quality in the New NHS

  3 UKCC Annual Statistical Report, 1997-98. UKCC, London.

  4 English National Board Annual Report, 1997. ENB London.

  5 Changing Times: a survey of registered nurses in 1998. Smith G and Seccombe I. Institute for Employment Studies, Brighton.

  6 Pay and Progression for Graduates 1997-98. Incomes Data Services Management Pay Review Research File 45. IDS, February 1998.

  7 Taking Part: Registered Nurses and the Labour Market in 1997. Smith G and Seccombe I. Institute for Employment Studies, Brighton.

  8 Pay Review Body Report for Nursing Staff, Midwives and Health Visitors, 1998.

  9 Department of Health Statistical Bulletin: NHS non-medical workforce in England. Department of Health, 1998.

  10 Department of Health Statistical Bulletin: Private hospitals and nursing homes. Department of Health, 1998.

  11 Audit Commission 1997, Finders, Keepers: the Management of Staff Turnover in NHS Trusts.

  12 Department of Health analysis of NHS Trusts Financial Returns.