The social care workforce is struggling, with an estimated 44% turnover rate across the UK and numbers entering into social care continually dwindling. According to The State of the Adult Social Care Sector and Workforce in England report (Skills for Care, 2023) there are currently 152 000 unfilled workforce posts in social care.
It is estimated that social care contributed £55.7 billion to the economy in England in 2022-23 (Skills for Care, 2023), providing a positive boost in the current poor economic climate. But there are significant workforce challenges that have impacted the recruitment and retention of staff into social care. Some particular variables can affect turnover, such as access to training, and a lack of career structure, which may be a disincentive to some staff to continue working in the sector.
Care homes now support people with complex needs. Hence, the future of our social care nursing workforce is reliant on the higher education institutions to prepare future nurses for this environment. This requires a focus on person-centred approaches that will enable students to learn about ‘what matters to people’, as opposed to relying on knowledge about ‘what is the matter with people’. It is these salutogenic principles (a focus on the origins of health rather than those of disease) that support wellbeing that could empower students to understand the complexities of the individuals and families supported through social care and help students provide person-centred care.
Although the nursing curriculum is predicated on the Nursing and Midwifery Council's (NMC) education standards (NMC, 2018), which promote a person-centred approach, there is a need to emphasise the additional skills that are required for working in a nursing home context. According to the Queen's Nursing Institute (QNI) Standards of Education and Practice for Nurses New to Care Home Nursing these are:
‘… additional emotional intelligence and the use of ‘soft skills’ such as diplomacy, sensitivity and a heightened awareness that the Care Home is the individual's home. The Registered Nurse will have a clear focus on person-centred care, giving the resident and their families choice and a voice about the care they receive through listening and shared decision making.’
There is a focus on kindness, on being human and, importantly, on ensuring that we provide opportunities for students to experience this through their learning and development within a social care context. However, although the nursing curriculum is based on a 50-50 theory-practice split, the vast majority of placements are located in primary or secondary care NHS organisations, which vastly limits the opportunity for students to experience the benefits that social care offers. Subsequently, many undergraduate students are missing out on opportunities to learn about social care.
This lack of opportunity for students to learn in social care environments has subsequently contributed to the silencing of the voice of social care nursing. There is now an urgent need to provide incentives to encourage nurses into social care careers, by being exposed to and valuing the essential nature of the social care/care home nurse. As the QNI standards suggest, care home staff need to provide safe and effective care for this population. To accomplish this, we need to develop a more person-centred curriculum that advocates the values of social care nursing through greater exposure to this environment, which is empowered and driven through theory and practice.
Education now
In England there has been a recent government announcement to develop a national care career structure, funding apprenticeships and developing digital training (Department of Health and Social Care and Whately, 2024). This includes a commitment to improve and support the domestic care workforce through training and the launch of the care workforce pathway for adult social care. The pathway elicits four clear role categories, which are intended to align across the sector:
- Role category A: new to care
- Role category B: care or support worker
- Role category C: supervisor or leader
- Role category D: practice leader.
This marks a starting point in supporting and developing the workforce, providing opportunities for clear career progression and access to professional programmes of study. However, this will only be achieved on adoption of the pathway across the sector through working in partnership with the government, NMC and QNI (individuals from these organisations need to proactively support this) and our colleagues in social care. These include the Social Care Nursing Advisory Councils (SCNACs), social care academies and Skills for Care (2024), which can work alongside educationalists to change the mindset of our students and the sector as a whole. For example, this could support the introduction of social care nursing as a ‘fifth field of practice’. Currently, there are four fields of practice in nursing: mental health, children and young people, adult, and learning disability, and it is not clear where or how social care is reflected across all the fields.
We propose that a fifth field of practice could focus on social care so that we can shift the mindset of our future nursing workforce and promote opportunities through educational placements and curricula redesign. We have an opportunity to make a real difference and promote a biopsychosocial, person-centred model of care that builds on the salutogenic principles needed across the lifespan of the populations we care for. This could be just the start.
What difference would a fifth field of practice make?
Introducing social care as a fifth field of practice will empower educationalists to enable students to learn about social care through creating space in the curricula that facilitates and supports innovative placement developments. There is already some great work in the development of placements in social care, and indirect supervision and assessment models are now being widely used for learners to experience a wide range of social care placements.
For example, in Cheshire and Merseyside more than 200 placements across private, independent and voluntary organisations have been opened and learners experience placement opportunities to learn to communicate effectively with people across the lifespan. This includes with people with learning disabilities, challenging behaviours, people with communication and language difficulties and people with mental health needs across diverse cultural and situational backgrounds. This includes seeing social prescribing in action, end-of-life care, further education and social enterprises, to name a few. Feedback from learners has been extremely positive (Knight et al, 2023).
Clearly, introducing a fifth field of practice could have benefits for our students and the future social care workforce. Using care homes as placements could help to highlight the person and the power relationship between the person and the nurse providing care. Moreover, it is an opportunity for students to understand how being in someone's home can dramatically influence this power dynamic. Equally, the autonomy of the student nurse within a care home setting may be greater than their experience in a traditional NHS ward setting.
However, full preparation through curricula and careful placement expansion is essential in taking this forward. The salutogenic approach promoted through this psychosocial model is central to the practice, hence a fifth field of practice is needed to promote this philosophy in student nurses. The opportunity to develop leadership and management skills through person-centred salutogenic placements in social care could transform student nurse understanding and improve future attraction to social care careers.
What can CPD and specialist pathways offer?
Other educational efforts to promote social care nursing have been observed through the development of continuing professional development (CPD) and specialist pathways. Working through NHS England's Workforce, Training and Education Directorate and the SCNACs, changes are being implemented to support innovative and creative educational programmes based around addressing emotional intelligence and kindness, as well as the clinical elements of frailty and leading the care team through empowerment. However, there is additional work that could be done to promote social care careers.
A joined-up approach is needed in a social care sector that is currently diverse and has a complicated and confusing collection of accredited and non-accredited training organisations. This creates confusion for social care providers on how to access appropriate and nationally recognised education provision.
Face-to-face learning is now being complemented with online delivery. Individuals can now access learning flexibly, on-the-go and via a range of different modalities.
Despite these advances, more needs to be done to facilitate career progression in social care. Significantly, the reform of the Standards of Proficiency for Community Nursing Specialist Practice Qualifications by the NMC (2022) has placed an emphasis on the advanced skills required for nurses to support the most vulnerable in society residing in a variety of community settings. The new standards have, for the first time, acknowledged social care as a diverse and newly emerging specialist field of practice.
The QNI (2022) has taken this one step further through the publication of its field-specific standards for specialisms in community nursing of which there are nine in total, including adult social care. The standards provide a platform to build upon the core requirements of the NMC, supporting quality assurance of educational programmes and preparing nurses to work at an advanced level within the field of social care practice (QNI, 2022). These steps are not only welcomed by those working in adult social care but also promote the Government's proposed strategy and vision of creating an adult social care workforce, harnessing education and training and an opportunity to value and recognise the skills required to deliver high-quality person-centred care for the future.
What next?
Much work has already been taking place to support student learning through placement expansion into social care. The opportunities for 2024 are exciting, but we need to lobby higher education institutions and academies and use our emerging evidence to change mindsets and support these amazing innovations.