The challenges for nursing in Scotland in the 21st century are similar to those of many other developed and industrialised countries. Dealing most recently with the COVID-19 pandemic, nurses are also looking after people with degenerative or long-term conditions, mental health problems, and conditions associated with an ageing population. There is also the need to move the emphasis from acute to community care (Nursing and Midwifery Council (NMC), 2018a; Glasper, 2020). In addition, although Scotland is a relatively small country, it has a variety of population profiles, ranging from densely populated urban conurbations to remote, sparsely populated and relatively inaccessible areas, which demand different approaches to healthcare provision. Devolution of health and social care to the Scottish Parliament has seen the continued decentralisation of power as an increasingly important part of policy, and a central foundation in redesigning initiatives to reduce health inequalities and address key areas for health improvement. This approach has also been reflected in the evolution of the recruitment, education and retention of nurses in Scotland (Scottish Government, 2017; NHS Education for Scotland (NES), 2020).
Flexibility in learning that emphasises student choice, has long been considered the key to enhancing the quality of nurse education, and satisfying highly diverse student needs (Raymond et al, 2016). It is often associated with the terms ‘open learning’, ‘blended learning’, ‘distance learning’, ‘e-learning’ and, most recently, ‘virtual learning’. The Open University (OU) offers this flexibility and is highly suited to today's students who wish to become the nurses of the future but expect to access the learning environment in ways that suit their lifestyles and learning preferences, and the needs of future employers (Vicary et al, 2018).
The OU was founded in 1969 under Harold Wilson's Labour government. The aim was to ensure social justice through easy, open and fair access to higher education for all. Jennie Lee, a coalminer's daughter from Fife, was known as the ‘midwife’ of the OU and was responsible for ensuring the delivery of high-quality education predicated on being open to all people, places, methods and ideas. This remains the guiding ethos of the OU today (OU, 2020a).
In 2002 the OU nursing programme was first introduced to encourage and support health care support workers (HCSWs) become registered nurses (RNs). From that early starting point, the OU nursing programme now combines distance and e-learning pedagogy with work-based learning, delivered in partnership with health and social care employers across the UK, to promote both academic literacy and professional nurse identity and standards (Watts and Waraker, 2008; OU, 2020b).
This article illustrates how the Open University in Scotland (OUiS) is working to equip new and existing nurses with the required knowledge, skills and experiences to meet the changing demands on the profession through a diverse and inclusive range of study programmes.
Recognition for nursing
As the first wave of the COVID-19 pandemic reached its peak in the UK from March to May 2020, the ‘clap for carers’ campaign demonstrated the strong public appreciation of nurses and other key workers in providing care during the pandemic (Wood and Skeggs, 2020). The fundamental role that nurses play in care delivery was also highlighted by the UK Prime Minister, Boris Johnson, who praised the nurses who aided his recovery from COVID-19 (Ford, 2020). In Scotland, First Minister Nicola Sturgeon, regularly conducted COVID-19 briefings alongside the Chief Nursing Officer, Fiona McQueen, emphasising the important role played by nurses in the delivery of care during the pandemic.
Although this public and political appreciation of nurses is welcome, the nursing profession continues to face many complex challenges. These are summarised in Box 1.
Box 1.Challenges facing the UK mursing profession
- Rapidly falling numbers of nurses from EU countries working within the NHS as a result of Brexit and the resulting uncertainty around future residential status and permissions to work
- Reducing student nurse recruitment across all four UK nations
- Rising nurse disillusionment caused by being unable to deliver high-quality patient care in overstretched clinical environments
- Falling retention as increasing numbers of newly qualified nurses leave the profession
- An ageing nursing workforce who may be subject to challenging personal circumstances or ill health
- Funding shortfalls for the provision of nurse education, for example, the removal/reduction of nursing bursaries in England
Source: The King's Fund, 2015; NMC, 2018a; Jones-Berry, 2018; Glasper, 2020
High student nurse attrition rates are a significant issue across the UK, and it is estimated that as many as 1 in 4 student nurses leave before the end of their nursing programme, citing finances and lack of understanding of what studying a nursing degree programme entails (Jones-Berry, 2018; Glasper, 2020). The Health Foundation (2019) found that student attrition rates ranged from 50* to 5* across different universities, suggesting wide variation in completion rates (Health Foundation, 2019).
However, figures released in August 2020 revealed that the number of students accepted on to nursing programmes across Scotland has increased by 16* and the OUiS continues to recruit students to the number of places commissioned by the Scottish Government (Royal College of Nursing, 2020).
Glasper (2020) identified the changing demographics of student nurses and suggested that having flexible educational programmes and routes to nursing registration may go some way to addressing some of the challenges for student nurse recruitment in the future. The OU is dedicated to distance learning and excels in providing flexible, high-quality online learning that is accessible to all students from across Scotland.
Nursing with the OU
In 2020, the OU was the only provider of NMC-approved nursing programmes in all four fields of practice (adult, mental health, learning disability and child health) across all four nations of the UK (NMC, 2018a; OU, 2020b). With health and social care devolved to the governments of Scotland, Wales and Northern Ireland (The King's Fund, 2015), the OU is uniquely placed to deliver nursing programmes that address national needs while meeting the specific local and regional requirements of each nation within the UK.
The OU nursing programme has many distinct advantages for nursing students and employers alike. While studying with the OU, nursing students can remain in employment as HCSWs, and ‘earn as they learn’, which can materially reduce the financial hardship that some student nurses experience. Financial hardship is a significant contributory factor to the high student nurse attrition rates across the UK (Glasper, 2020).
Employers who support their HCSWs in the OU nursing programme can retain their workforce while they are studying and as nurse registrants on completion of their nursing programme. This, in turn, can help improve staff motivation, morale and job satisfaction which in turn contributes to reducing acute nursing staff shortages for many employers as ‘they grow their own workforce’ (Jones-Berry, 2018).
Online distance learning approaches offer many opportunities for collaborative learning, including the ability to communicate with peers and colleagues regardless of geographic location. Although many UK higher education institutions (HEIs) have embraced virtual learning environments, institutional and cultural barriers and challenges continue to restrict the successful introduction and acceptance of virtual learning (Stott and Mozer, 2016). The OU, with its 50-plus years of experience of distance and virtual learning, offers flexibility to nursing students as online and distance learning materials can be accessed at any time, in any place.
Nursing with the OUiS
Purposefully designed for HCSWs sponsored by their employers, the OUiS programme promotes widening participation in higher education and enables employers to invest in and develop their support workforce. Partnership working between the university, employers and education commissioners is crucial to its success and involves joint recruitment and selection of applicants/students to the OUiS. NHS and social care partners provide placement areas for work-based learning and employ practice education facilitators to monitor learning environments. NHS boards are also responsible for ensuring standards for student supervision and assessment (SSSA) are fulfilled and areas have enough supervisors/assessors to support students (NMC, 2018b). The Scottish Government is committed to improving the recruitment, education and retention of nurses and has accepted the recommendations made in the Chief Nursing Officer's Commission on Widening Participation in Nursing and Midwifery Careers (Scottish Government, 2017). This report recommended developing a clear pathway for HCSWs to progress their career into nursing and midwifery. The HEIs providing pre-registration nursing programmes (PRNPs) are also required to confirm that students have the necessary capability in numeracy and literacy to meet the programme outcomes (NMC, 2018).
HCSWs make up 26.7* of the nursing and midwifery workforce in NHS Scotland, meaning there are around 16 000 skilled staff with the potential to be qualified and expert nurses, building on their practical knowledge, skills, experience and realistic insight into nursing in Scotland today (Information Services Division, 2018). In keeping with the OU's commitment to widening participation, the admission criteria are set at the minimum required by the NMC (Draper et al, 2014; NMC, 2018a). This means that HCSWs who are not eligible to enter traditional nurse education due to high entry requirements are offered an alternative route to achieving their ambition, something that is of value to both students and employers.
However, there is no minimum education qualification requirement to be an HCSW and no national formal qualifications or training programme for HCSWs across Scotland. Therefore, even with lower academic entry requirements, many HCSWs still lack the basic qualifications required to apply for a PRNP.
Within the CNO's report (Scottish Government, 2017), the OU pilot project in partnership with NHS Grampian and North East Scotland Colleges (NESCOL) was cited as a potential solution to facilitate pathways into nursing. This pilot project was fully funded by the Scottish Government to support and help HCSWs achieve the necessary entry qualifications. This work proved to be successful, with individual HCSWs securing the opportunity to study an introductory OU module that credited them for their literacy qualification. Working in partnership with NESCOL, they were also able to study for a numeracy qualification at Scottish Credit Qualification Framework (SCQF) Level 5.
This project proved to be very successful in assisting staff to obtain the necessary qualifications, as well as building their confidence in their ability to study for an academic qualification. This work continues and was rolled out more widely in Scotland with an additional 2 years' funding from the Scottish Government to support further cohorts and a dedicated project manager was appointed. Scottish Government funding for this project concluded in October 2020, but this initiative has been recognised as a valuable means to provide pathways into nursing and articulation routes. HCSWs wishing to apply in the future will be directed to the Student Awards Agency Scotland for a part-time fee grant. In recognition of the success, 31 students progressed on to stage 1 and nine students progressed to stage 2 of the BSc (Hons) Nursing (Adult, Mental Health and Learning Disability) degree in 2020 and the OU has committed to a further 2 years' funding for this widening access to nursing work to continue.
Strong values around equality and the right of everyone to have the opportunity to study and develop are core to the ethos of the OU nursing degree across the four nations of the UK.
In supporting students across Scotland, the OU places significant value on the widening access model and students and employers report how the pastoral, academic and practice support contributes to their academic and professional success, leading to students being fit for employment and able to progress in their careers. This partnership between the OU and practice provides a community of learning to ensure that students receive a student-centred experience. There are various roles that are vital in supporting the student through their studies (NES, 2013; Kyle et al, 2020). During the pandemic this has brought additional challenges for the staff tutors and practice tutors who strive to support students and employers through the virtual learning environment. In addition, the associate lecturer role supports students in regular tutorials online and throughout their programme of study.
The main drivers for the Scottish Government commissioning nursing places with the OUiS are threefold:
- To meet requirements around recruitment and retention of nursing staff in remote and rural parts of the country
- To widen access to nursing education for people who, for whatever reasons, are unable to access nurse education through more traditional routes.
- To facilitate HCSWs to become RNs (NES, 2018).
Adults returning to education often have multiple competing priorities in their lives, including family and financial burdens that can have a significant influence on their education journeys (Merrill, 2015).
The OUiS nursing programme was initially offered in partnership with remote and rural health boards. Establishing and maintaining partnerships with key people in the health boards meant that the distance learning nursing programme could be delivered locally with most of the practice learning taking place within the students' own health board, making it more accessible to HCSW with caring responsibilities and community ties. The full course fees are paid by the Scottish Government, with additional finance provided to the employing health board to allow students to be released from their HCSW role for practice learning experiences in a variety of different practice settings, and potentially some paid study time. This means that patients, colleagues and the broader NHS organisation can retain a valued and experienced HCSW while supporting their professional development into a nursing career.
As demand for this programme has grown, new partnerships have been forged to deliver this programme across new health boards and care home organisations in Scotland. This has brought new ways of working to manage practice learning opportunities, working alongside and in partnership with other HEI colleagues in Scotland. OU nursing students in Scotland are recruited from the existing HCSW workforce. This approach differs markedly from other HEIs in Scotland, who are likely to have much higher academic entry requirements and offers an opportunity for study that would potentially have been beyond the reach of many HCSWs. Additionally, this means that the OUiS is not working in direct competition with other HEIs in specific parts of the country. Instead, and importantly, the OUiS provides a tailored opportunity to a group of people who may never have been able to study towards being a registered nurse. This particular group of staff working in the NHS and more recently, the care home sector, have the flexibility to study their nursing degree at the same time as retaining the security of their substantive role as an HCSW.
The success and value of this approach are best summarised in the words of two students who have had a supportive and rich experience from working and studying with the OUiS. As one student who began their journey with the OUiS on the widening access route explained:
‘I started my journey with the Open University in 2019. I was very anxious but was given great support by my mentor. It has been hard work, but with the Open University, I have been able to fit my studying around my family and work. I have now been accepted onto the Pre-Reg Nursing Programme Level 2 and look forward to the challenge ahead.’
And another who has completed their journey said:
‘My employers have been a tremendous support. I love the interaction with patients and their families, allowing me to build a rapport so I can provide them with the best possible care.’
Transitioning from student to newly qualified nurse can be overwhelming. However, employers are clear about the requirements of the OU programme and believe that students are well prepared for professional practice on completion of their studies. Many go on to have well-established nursing leadership roles and excel within the chosen professional careers.
Conclusion
PRNPs ensure that nurses of the future are equipped to meet the competencies and expectations of being a qualified practitioner. The OU is committed to safeguarding the ongoing strategic development of nurse education, ensuring that there is a workforce with the necessary knowledge, skills, aptitude and compassion to care professionally for patients and their families whether in the hospital or community environment. The COVID-19 pandemic has unexpectedly introduced many challenges to all of our lives, but it has also brought widespread public recognition of the nursing profession. It is often challenging to articulate the value of nursing, what nurses do, where they work and the contribution they make. With the publicity and the public ‘clap for carers,’ there was a true recognition of the benefits nurses bring to patient and family care (Harding, 2020). In October 2020 the OUiS opened its doors to all four fields of nursing with an emphasis on supporting pathways in remote and rural areas. The OUiS will continue to ensure nurses have the right preparation and ongoing support to deliver the population demands wherever they are based in Scotland, and that nurses are fit for purpose for today, tomorrow and beyond.
KEY POINTS
- This article concerns nurse education with the Open University specifically focusing on Scotland
- Although there are shortages to nurse recruitment and retention across the UK, in Scotland the landscape is somewhat different, and greater support for students is required in remote and rural areas of Scotland where nursing care is vital
- Due to COVID-19, there has been a greater emphasis on nursing and what nurses work entails and the OUiS continues to recruit the commissioned numbers of places
CPD reflective questions
- What do you see are the main strengths of studying nursing with the Open University?
- If you work in another country of the UK, would a similar scheme encourage more healthcare support workers into nursing in your area?
- Think about how more could be done to support nursing students in your area and encouraging support workers to embark on nursing training