Examining the local, international and demographic issues around planning the nursing workforce for the future, and what senior nurses need to consider
Chris Barrett, PhD, is academic adviser; Faye Gowing, BSc, is information analyst; Emma Kingston, BA, is critical issues manager; KateLightfoot, BA, is nursing and midwifery adviser; all at the NHS Workforce Review Team.
Barrett, C. et al (2009) Exploring strategies and resources to plan the nursing workforce of the future. Nursing Times; 105: 29, early online publication.
The government proposes that nurses will be involved in the design and delivery of future services. This suggests it is crucial that senior nurses are informed about workforce issues.
This article describes global and national workforce planning issues in nursing, workforce planning in the UK and the role of the NHS Workforce Review Team. It identifies the crucial knowledge base for senior nurses who may be involved in planning for the future workforce and resources available to help them.
Keywords: Workforce planning, Nursing workforce, Skills, Education
- This article has been double-blind peer reviewed
These are exciting times for the nursing workforce, with two current national initiatives that affect the future of all nurses.
The first is the Prime Minister’s Commission on the Future of Nursing and Midwifery (Department of Health, 2009). This aims to produce the first full-scale review of nursing for nearly 40 years (McLellan, 2009) and is closely modelled on Lord Darzi’s NHS Next Stage Review (DH, 2008a).
This initiative will be welcomed by the nursing profession, for, although Lord Darzi’s report included nursing career pathways and national standards for advanced nursing roles, it had a predominantly medical focus. The Commission on the Future of Nursing and Midwifery is intended to produce rapid results and report in March 2010.
The second initiative is the establishment of the Care Quality Commission (CQC), which regulates the quality of health and adult social care from April 2009 (Young, 2009). For the first time, NHS providers such as hospitals and ambulance services must be registered with the CQC to show they are protecting people from the risk of acquiring infections such as MRSA.
The intended outcome of these initiatives is clarity on the competencies, skills and support that nurses need to take a key part in planning and delivering a good-quality nursing service. This requires the examination of nurse education and training.
However, more than this may be needed to ensure the profession is fit for purpose. Young (2009) has expressed concern that the new commission could delay the pre- and post-registration nursing reforms on which the profession has just been consulted (DH, 2008b; NMC, 2008).
Also, there is no national commission on planning the future nursing workforce. At present this activity is carried out by workforce planners and/or human resource and financial teams and education commissioners at strategic health authority and trust level.
Workforce planning is not an exact science, nor is it just about numbers. It is about anticipating potential imbalances between the supply and demand for different skills in time for necessary action to be taken (Mullins, 1996).
Senior members of the nursing profession will be involved in the design and delivery of future nursing services. If they are to direct the use of the workforce effectively to deliver the best quality patient care, these nurses will need to be aware of the issues in workforce planning. They will be expected to have insight into planning processes such as analysis, modelling, review and redesign, and know how to access the resources to support these processes.
A recent rapid review of workforce planning literature to identify reported good practice and workforce planning techniques – in the UK and internationally – found evidence of successful planning to be patchy, with many gaps in empirical knowledge (Bosworth et al, in press).
Although it could therefore be anticipated that the body of nursing literature on this topic would be small and descriptive in nature, a number of nursing papers and reports have focused on the following global and national issues.
Nursing shortages are a global concern and the major challenge for all countries is to establish workforce planning mechanisms that meet demands for health care and provide workforce stability (Little and Buchan, 2007). Identified mechanisms to supply nursing resources are often short term, fragmented and inadequate (International Council of Nurses, 2006; 2005).
In many countries, a nursing workforce plan is needed that allows for contextual drivers of supply and demand, and for issues of capacity, capability and productivity.
Many industrialised countries have ageing workforces and are likely to experience a large exodus of nurses at retirement (ICN, 2008). There is concern that this trend, if not addressed, is set to deepen the shortage of employed nurses, particularly where there is a shortfall of new nurses.
Issues of immigration and migration create further nursing workforce problems in developing and underdeveloped countries, at both national and local levels. International recruitment drains the active nursing workforce of poorer developing countries.
As nursing shortages in the western world continue to worsen, identifying best practice workforce models is increasingly important to address these problems.
Little and Buchan’s (2007) study of the effects of migration, and definitions and models of self-sufficiency/sustainability, showed that these models do exist within nursing workforces worldwide.
Common characteristics of these successful models include: collaboration; government support; short- and long-term planning; significant expansion of training capacity; limited reliance on immigrant workers; and significant monetary investment.
Nowhere is a sustainable global nursing workforce more crucial than in caring for older people and those with long-term conditions. The developed world’s population is ageing; overall, its long-term care workforce is in shortage. This problem is expected to increase because of parallel socio-demographic factors (Hussein and Manthorpe, 2006).
Developed countries are increasingly turning to overseas to find people for this specific workforce. Browne and Braun (2008) identified trends that influence the availability of immigrant workers in the US to provide long-term care.
National issues for the UK
In the UK, the RCN has published trends and predictions for the workforce in several reports and five supplements (RCN, 2004a; 2004b). Their key messages are shown in Box 1.
Box 1. Trends
- The workforce is increasing overall but numbers of health visitors, district nurses, learning disability nurses and midwives have decreased.
- Not many nurses return to nursing after leaving, despite encouragement to do so.
- There has been a 46% increase in the number of HCAs.
- The UK nursing workforce is an ageing population.
There were 651,709 nurses on the NMC (2007) register in March 2007. The split by branch is as follows: 77% adult; 13% mental health; 5% children; 3% learning disabilities; and 2% general.
The NHS is the largest employer of nurses in the UK. In September 2008, there were 382,496 qualified nurses employed in the NHS in England, a full-time equivalent (FTE) of 309,733, and an FTE to headcount ratio of 0.81:1 (The NHS Information Centre for Health and Social Care, 2009).
The government has historically set targets to increase numbers of registered nurses and midwives in the NHS as follows: in England, 80,000 by 2008 (DH, 2003); in Scotland, 12,000 by 2007 (Scottish Executive, 2003); in Wales, 9,000 by 2010 (Welsh Assembly Government, 2003a; 2003b). Northern Ireland has similar aspirations. Data shows that, between 2003 and 2008, the NHS nursing workforce in England increased by around 22,000.
In line with the global picture, the UK workforce is ageing and an estimated 180,000 nurses will reach retirement age over the next decade (RCN, 2006).
A recent large study (Laine et al, 2009) of 30,037 European registered nurses, including those from the UK, sought to determine the occupational factors affecting their decision to leave the profession before reaching retirement age.
The nurses showed concern about becoming unemployed and the difficulty of finding a new job if laid off, and qualitative job security (being transferred to another job or changes in work schedule). In this study, 15% of respondents reported thoughts about leaving the profession.
In some specialties, the ageing profile is particularly marked. For example, in the small specialty of dermatological nursing, many experienced specialist nurses are due to retire by 2015 (Penzer, 2007).
The professional profile is altering, with increasing numbers entering nursing at an older age and with previous career experience (ICN, 2008).
There has been an explicit policy emphasis on international recruitment to increase the NHS workforce (Buchan and Seccombe, 2005). Within the UK, internationally recruited nurses have historically been more predominant in England (RCN, 2004a; 2004b). A postal survey of the demographic profile of 1,000 London-based, international nurses (Buchan et al, 2006) concluded it was a critical issue for UK policymakers to determine whether these nurses will stay on in the UK.
NMC data in 2008 showed that the number of international recruits entering the NHS nursing workforce has sharply decreased from 12,872 in 2002–2003 to 2,846 in 2007–2008.
Another change to the nursing profile will occur as plans for an all-degree level registration profession come into effect.
Many human resource management issues affect retention. It is beyond the scope of this article to explore them, but the difficulties reported in mental health nursing serve as an example. Gilbody et al’s (2006) systematic review of those working in psychiatric care found that they suffer some of the highest levels of job dissatisfaction and burnout in the healthcare workforce. This would suggest that evidence of effectiveness and efficiency of management policy outcomes should be considered in workforce planning.
However, there is limited evaluative research in this field.
Similar difficulties in recruiting and retaining adequate numbers of mental health nurses, and the increasing age profile of this group, have been documented in Australian literature (Gough and Happell, 2007). The authors dramatically concluded that a workforce crisis was rapidly approaching, yet they reported there had been no comprehensive, coordinated collection of labour force data in Australia.
Workload is often cited as influencing levels of job satisfaction and decisions to leave or retire from the UK nursing workforce.
Workload is a complex concept. The quality and nature of the work, resources available and pay and status are important variables.
Gemmell et al (2009) illustrate this well in their recently published assessment of the workload in general practice in England, before and after the introduction of the GP contract and the quality and outcomes framework. By analysing the workload of doctors and nurses pre-2003 and post-2005, this study found that nurses now dealt with more complex problems and absorbed a higher proportion of the clinical workload. Their work intensified as they accepted new roles while maintaining old ones.
In summary, the global and national literature suggests there are many nursing workforce issues including: major supply issues; an ageing population; looming retirement levels; migration and immigration; nursing shortages; and a changing professional profile.
Care of older people and services to meet the needs of people with long-term conditions and mental illness raise further demand issues.
Workforce planning in the UK
The House of Commons Health Select Committee (2007) criticised a perceived NHS failure to develop and apply effective workforce planning. The NHS Next Stage Review emphasised the importance of having a ‘high-quality workforce to deliver high‑quality care’ (DH, 2008a).
Many aspects of the NHS conspire to make workforce planning challenging, not least the ongoing development of new roles, structures and services. Critics of workforce planning in the UK rarely acknowledge these inherent difficulties in the NHS (Bosworth et al, in press).
At trust level, these problems have often resulted in adopting a firefighting approach to immediate, practical problems (such as filling individual vacancies), rather than developing a long-term, strategic plan. Nationally, the NHS’ expanding size and complexity (there are 1.3 million NHS employees, 148 PCTs and 237 other trusts) has contributed to the increasing prominence of workforce planning as a key issue in English healthcare.
The NHS Workforce Review Team (WRT) is a group of dedicated workforce planners who provide objective modelling, analysis and evidence-based recommendations to enable patient-centred and clinically driven strategic decision-making in the workforce in England.
WRT works with stakeholders including the DH, SHAs, PCTs and NHS trusts to support and build capability in workforce strategy and planning throughout the service. It also aims to identify workforce priority areas and groups.
Effective workforce planning has three basic elements: assessing how many and what type of staff are needed (demand); identifying how these staff will be supplied (supply); and determining how a balance between demand and supply can be achieved (Buchan, 2007).
WRT modelling indicates that, currently, the overall nursing workforce supply in England largely meets demand. However, certain areas remain difficult to recruit to (intelligence suggests that nursing homes in particular rely heavily on international recruitment). The latest forecasts show that if current nurse training places are maintained, there will be a fall in the number of nurses in the future.
Knowledge base and resources
There is much discussion about what Modernising Nursing Careers will mean and how the profession needs to change to deliver nursing care into the future.
Proposals on academic preparation are well advanced, with plans for degree-level registration and career pathways.
Locally, senior nurses will experience different pressures on services in different parts of the UK. Those seeking planned and integrated management of the local workforce will need knowledge and understanding of workforce analysis, review and redesign.
Senior nurses will need to build a workforce planning toolkit that is specific to their situation. This will need to include knowledge of current nursing staff and their skill-mix, and data on other healthcare professionals.
In many cases, planning a future workforce is about reshaping an existing one, as 60% of staff who will deliver services in 10 years’ time are working in health care now (DH, 2008a).
Important questions to ask are: what is the age profile, and how many will reach retirement within the planning timetable? A nursing ‘Christmas tree’ (Fig 1) may help nurses to plot the workforce. Local planning, including staff profiling, needs to feed into a national plan for future nursing numbers.
Fig 1 shows the percentage of NHS nurses (FTE) in England working in each Agenda for Change band from bands 5–9.
A Christmas tree can be used as a visual representation of the workforce. This one shows that a large proportion of the NHS nursing workforce in England currently works at AfC band 5 and that there are very few nurses working at band 9.
Once the profile of the existing local workforce is understood, how this might need to be changed to adapt to a new way of working needs to be assessed.
As well as recognising the future shape of the service that is required, and identifying the skills to deliver it, consideration needs to be given to how existing staff will be educated or retrained.
Horizon scanning (looking at future medical/healthcare developments and technologies) and scenario planning are useful tools in determining roles that are envisaged. Some useful questions are included in Box 2.
Box 2. Useful questions for workforce planning
- What skill-mix will the new multidisciplinary team need and how will the team work together?
- Is there a development programme for support staff?
- Do nurses in the team need to achieve recognised, accredited qualifications?
- Can they deliver the specialist and advanced nursing care needed in the future?
- What investment will this require?
If the service planned needs senior nurses, perhaps leading teams, managing a caseload or delivering high-level clinical skills, one option is investing in the existing workforce.
This may require a change in skill-mix and investing in support or auxiliary staff to deliver aspects of clinical and administrative roles. Nurses may be recruited to specific roles with a development programme.
Integrated workforce planning requires senior nurses to work with workforce planners, human resource teams and education commissioners at SHA and trust level. Collaboration with colleagues in finance is particularly important in this time of economic constraint.
There may be a need for some formal education (an example might be because team members are required to prescribe or to take on new assessment procedures).
Education programmes may already be available for commissioning. However, senior nurses may need to become involved in helping higher education institutions to develop and deliver new programmes.
These changes may need to be implemented months or even years before the intended effect on the skill-mix of the workforce is achieved.
Nursing is, at present, usually a three-year training programme and will probably remain so under Modernising Nursing Careers – hence the need to consider workforce strategy at the time of planning new services.
The WRT website offers an extensive range of resources for senior nurses involved in workforce planning (Box 3).
Box 3. Online resources
The Six Steps Methodology to Integrated Workforce Planning is available on the Healthcare Workforce Portal website. The guide aims to set out in a practical framework elements that should be in any workforce plan.
The papers cited in this article provide further material. Other resources include a report prepared for the RCN (Buchan, 2007), which comments on the status of nursing workforce planning systems and data in the NHS. It contains much detail of workforce data sources.
In 2007, many relevant online papers were published in Employing Nurses and Midwives. These included: ‘Consultant nurses’; ‘Nursing workforce research migration pattern’; ‘An all-graduate profession’; and ‘Encouraging older nurses to continue working’.
The National Nursing Research Unit (NNRU) at King’s College London provides access to research online, for example on the importance of job satisfaction in early career in preserving the workforce (NNRU, 2008).
Senior nurses in community care may find Hurst’s (2006) study provides information to enable evaluation of the size and mix of their workforce. Hurst reported on a large workforce database of PCTs in England and an annotated bibliography about community and primary care teams.
An essential component in any healthcare provision is workforce planning to ensure there are enough nurses with the right skills, in the right place, at the right time.
The full range of settings in which care is delivered must be considered when evaluating national demand. Healthcare demands are rising; the UK has an increasingly ageing population, public expectations are high and changing disease patterns mean new challenges.
It is equally important that senior nurses responsible for delivering local clinical services understand the principles of planning a healthcare workforce and work with other clinicians as services and educational curriculums are being designed.
- Nursing Times is holding its annual Nursing Workforce Forum – Workforce Strategies to Deliver High-Quality Nursing Care on 6 October 2009. Click here or call 0845 056 7889 to book your place.
Future nursing workforce issues are:
- Supply: ageing, retiring, some specialty shortages;
- Demand: nursing care in the areas of long-term conditions, midwifery and child health, community, mental health and learning disabilities;
- The implications of all-degree level registration.
- Senior nurses need understanding of integrated workforce planning in health/social care.
Bosworth, D. et al (in press) Who does workforce planning well? WRT rapid review summary. Accepted for publication in Journal of Healthcare Quality Assurance (October 2009); 23: 1.
Browne, C.V., Braun, K.L. (2008) Immigration and the direct long-term care workforce: implications for education and policy. Gerontology and Geriatrics Education; 29: 2, 172–188.
Buchan, J., Seccombe, I. (2005) Past Trends, Future Imperfect? An Analysis of the UK Nursing LabourMarket 2004/2005.
Buchan, J. (2007) Nurse Workforce Planning in the UK. A Report for the Royal College of Nursing. London: RCN.
Buchan, J. et al (2006) Internationally recruited nurses in London: a survey of career paths and plans. HumanResources for Health; 4: 14. doi:10.1186/1478–4491–4–14
Department of Health (2009) Future of Nursing and Midwifery – Commission of Experts to Improve Quality ofPatient Care. London: DH.
Department of Health (2008a) A High Quality Workforce: NHS Next Stage Review. London: DH.
Department of Health (2008b) Towards a Framework for Post-Registration Nursing Careers. ConsultationResponse Report. London: DH.
Department of Health (2003) Staff in the NHS 2003: An Overview of Staff Numbers Within the NHS. London: DH.
Gemmell, I. et al (2009) Assessing workload in general practice in England before and after the introduction of pay-for-performance contract. Journal of Advanced Nursing; 65: 3, 509–515.
Gilbody, S. et al (2006) Can we improve the morale of staff working in psychiatric units? A systematic review. Journal of Mental Health; 15: 1, 7–17.
Gough, K., Happell, B. (2007) We can’t find the solution until we know the problem: understanding the mental health nursing labour force. Australasian Psychiatry; 15: 2, 109–114.
House of Commons Health Committee (2007) Workforce Planning. Fourth Report of Session 2006–2007. Volume 1. London: The Stationery Office.
Hurst, K. (2006) Primary and community care workforce planning and development. Journal of AdvancedNursing; 55: 6, 757–769.
Hussein, S., Manthorpe, J. (2006) An international review of the long-term care workforce; policies and shortages. Journal of Ageing and Social Policy; 17: 4, 75–94.
International Council of Nurses (2008) An Ageing Nursing Workforce. Geneva: ICN.
International Council of Nurses (2006) The Global Nursing Shortage: Priority Areas for Intervention. Geneva: ICN.
International Council of Nurses (2005) Nursing Workforce Profile 2005. Geneva: ICN.
Laine, M. et al (2009) Job insecurity and intent to leave the nursing profession in Europe. The InternationalJournal of Human Resource Management; 20: 2, 420–438.
Little, L., Buchan, J. (2007) Nursing Self Sufficiency/Sustainability in the Global Context. Geneva: ICNM.
McLellan, A. (2009) Commission aims to put nurses ‘at the heart of world-class NHS’. Nursing Times; 105: 9, 1.
Mullins, L. (1996) Management and Organisational Behaviour. London: Pitman.
National Nursing Research Unit (2008) Preserving the nursing workforce: the importance of job satisfaction in early career. Policy+; Issue 8, March 2008. London: NNRU, King’s College London.
NMC (2008) A Review of Pre-Registration Nursing Education – Report of Consultation Findings. London: NMC.
NMC (2007) Statistical Analysis of the Register 1 April 2006 to 31 March 2007. London: NMC.
Penzer, R. (2007) Dermatology nurse specialists need to show their worth. Dermatological Nursing; 6: 3, 6.
RCN (2006) Majority of New Nurses Unable to Find Jobs in the NHS, says RCN. London: RCN.
RCN (2004a) The Future Nurse: The RCN Vision. London: RCN.
RCN (2004b) The Future Nurse: The RCN Vision Explained. London: RCN.
Scottish Executive (2003) A Partnership for a Better Scotland: Partnership Agreement. Edinburgh: The Scottish Government.
The NHS Information Centre for Health and Social Care (2009) NHS Staff 1998–2008 (Non-Medical).
Welsh Assembly Government (2003a) The Review of Health and Social Care in Wales. Summary. Cardiff: WAG.
Welsh Assembly Government (2003b) Wales: A Better Country. The Strategic Agenda of the WelshAssembly Government. Cardiff: WAG.
Young, B. (2009) Shining a light on care. Nursing Management; 15: 10, 14–16.