As the largest professional group in the healthcare workforce, nurses have been at the frontline of a digital transformation. In this article, from our publication Working Futures, Professor Dawn Dowding and Dr Sarah Skyrme assess what this means for the workforce and suggest policy interventions.

• Ambitions for all NHS organisations in England to be paperless by 2024 will significantly impact the nursing workforce.
• Training, recruiting, and retaining nursing staff has become a key challenge for the UK – as recognised by the recently published NHS Long Term Workforce Plan.
• Strategies are needed to ensure digital infrastructure is in place and the workforce are fully trained in digital skills.

The nursing workforce and the NHS Long Term Plan

Globally, nurses account for nearly 50% of the healthcare workforce, and in the UK are proportionately the largest professionally qualified group of clinical staff. The UK has a shortage of qualified nurses, with an estimated 11.8% of roles unfilled. Nurses work across multiple settings such as mental health, children’s and learning disability services, in the NHS, the care sector, and for private companies.

The NHS Long Term Plan highlights how failure to address recruitment and retention will result in significant shortfalls of community nurses and mental health nurses in the NHS. Up until now, the UK has relied heavily on the recruitment of registered nurses from other countries, often from areas of the world facing their own nursing workforce challenges. Strategies outlined in the Workforce Plan, such as increasing the number of nurse training places alongside new training approaches (such as apprenticeship routes) will increase the number of nurses trained and recruited. However, policymakers in government and the NHS should also prioritise retention of the nursing staff we already have, providing opportunities for skills development to meet the challenges of caring for an ageing population with complex care needs.

Technological innovation, particularly in relation to Artificial Intelligence (AI), is frequently regarded as a viable solution to these challenges.

The ‘future’ health and care system

AI can undertake roles and responsibilities previously carried out by healthcare professionals (for example supporting decisions based on mammography images). While it is difficult to predict precisely what role some advanced technologies may have in terms of future nursing practice, it is evident that nurses’ work has already altered irrevocably since the pandemic, and this evolution will continue.

Healthcare is moving towards delivery models focused on providing care to individuals in their home or community, rather than the previous model of hospital-focused care. The national rollout of ‘virtual wards’ exemplifies this; individuals being cared for in their own homes via remote monitoring technology and care support, rather than receiving care in a hospital setting. The role of ‘diagnostic hubs’ and mobile screening, where health and care services are embedded in or visit local communities are also increasing.

Primary care, outpatient clinics and mental health services now provide telephone or video consultations alongside more traditional face-to-face appointments. We are also witnessing a greater emphasis on individuals taking control of their health, with an increased uptake in the use of mobile health technologies designed to support health and well-being.

What the transformation of care service delivery means for the nursing workforce
Moving to a digital environment with care provided remotely and contact via digital technologies rather than face to face, provides both challenges and opportunities for the existing nursing workforce.

Nurses of the future must be adept at using digital tools. Digital technologies have the potential to free up nursing time; one potential outcome of the generation of AI-based tools is that they will take on routine tasks and administrative duties. This could lead to a shift in the approach to staffing services that may encourage some nurses to stay in practice longer, as well as providing opportunities for delivering care in individualised, remote ways.

We can envisage a time when the general population will be holders of their own health data and manage their care options and health conditions using digital tools. This requires a change in relationships with health care professionals (not just nurses) and organisations that deliver care. For nurses, the skills to react and adapt to new realities and ways of working, (vital during the pandemic) will continue.

Current problems with digital infrastructure

For any digital solution to work effectively, you need good infrastructure, including Wi-Fi and access to the appropriate hardware and software. Nurses work across a variety of organisations, including acute hospitals, community organisations, homes, and the care sector. Our research highlights how in many areas of the country and across organisations these basic requirements are not met. There is a lack of equality in availability of internet access among the general population, with individuals on the lowest incomes (and often the highest healthcare needs) more likely to be without internet access or devices to connect to Wi-Fi.

Our study highlights how this inequality in access extends to nurses. Some organisations provide high quality internet access and devices to their staff – others are reliant on substandard digital infrastructure. Some nurses reported that they worked in environments with unreliable Wi-Fi and either lacked access to enough devices or were expected to use their own devices. Our study survey found that nurses who cannot afford a smartphone or equivalent device can be disadvantaged in terms of ability to perform their duties, with a respondent stating “Accessibility of smart phone, some staff can’t afford these”. Although nurses’ starting salary is £31k, many nurses work part-time and have childcare responsibilities. Considering living costs particularly in the South East of the country, it is quite possible that part-time nurses cannot afford this type of technology.

For many staff, the vision of a digitally-enabled, AI-supported care system is far removed from their current experience. If we are to enable the nursing workforce to work in new ways, then in the short-term, addressing inequalities in access and prioritising high quality infrastructure is key for health policy.

Digital literacy in the nursing workforce

In addition to a working digital infrastructure, the workforce needs digital skills. Over the last three years, there has been an expectation for healthcare professionals to adopt a variety of different technologies and tools. In nurses we found the most common technologies introduced included tele/video conferencing for online consultations, electronic methods for communicating between professional groups, and a variety of digital tools for remote monitoring of patients and documentation of care (such as electronic health records). These were introduced into a nursing workforce with significant variation in their ability and skills to use them effectively, and often with insufficient training.

Ensuring that the workforce has the skills it needs to use the current digital technologies deployed in the NHS and across the wider care sector is a challenge for health and care organisations and educators alike. Many NHS organisations have recognised this and have put strategies in place to provide strong professional nursing leadership in the form of Chief Nursing Informatics Officers or CNIOs – we recommend that this rollout continue apace.

As well as leadership, resources to enable nurses to develop digital skills are required. Many organisations offer their own training, and NHS England has produced a number of digital capability frameworks, though currently not one specifically focused on the nursing workforce. In addition, we need to ensure that nurses graduating from education programmes have the skills to perform in a digitally-enabled NHS.

It is often assumed individuals who have ‘grown up’ with digital technologies and use them daily will automatically have the required skills. However, it is clear from our research that this is not the case, and teaching students to use the types of tools currently used in the NHS and care sector requires a well-targeted approach. This also demands an academic workforce skilled and adept to provide that education, both currently and with a view to innovations in areas such as genomics and AI, which will require significant revisions to the way training is currently delivered.

Further Recommendations

To conclude, investment and strategy from government and NHS policymakers should focus on upskilling the current and future nursing workforce, as well as academic staff in HEIs, in digital skills competencies. This must involve ongoing training and support for the future, to enable skills development for innovations that are currently hard to predict. Recognition that nurses are essential to the effective and efficient delivery of care services should be included in planning to redesign services, and in the procurement of technologies to support their changing role.