Annex 3. Rapid review of the literature – policy and practice
Dr Maria Pollard and Margo Stewart, University of the West of Scotland, and Alan Gillies, NHS Education for Scotland.
Globally there is a shortage of nurses and midwives due to demand being greater than supply. This is further exacerbated by an ageing workforce and increasing age of the population, which brings increasing complexities to health and social care.  The challenge globally lies with recruiting and maintaining an appropriate workforce that reflects the population and educating that workforce. Areas that require consideration to address this challenge include:
- retention – keeping those currently in employment (professional development, autonomy)
- fair reward, improving the work environment, flexible working patterns
- clarity of access routes
- recruitment from a broad and diverse population, for example mature workers, ethnic minority groups, men, those with work-based experience vocational qualifications, non-traditional learners
- return to practice
- international recruitment.
Education mobility is central to quickly, efficiently and effectively educating people to become registered nurses and midwives. Birkhead et al.  describe education mobility as seamless academic progression by giving credit for previous education or experience without having to repeat content or engage in similar learning. This means developing a robust model where there is coordination of programme content between education institutions (schools, FEIs and HEIs). The benefits of education mobility include:
- lifelong learning and personal achievement
- growth of a registered workforce more quickly
- increased diversity of the workforce.
Cavendish  highlighted the need to: 'develop innovative funding routes for non-traditional staff to progress' and recommended the development of a 'robust career development framework for health and social care support staff, linked to the simplified job roles and core competences'.
A rapid desktop review was undertaken to identify other countries (r UK and international) approaches to widening access to nursing and midwifery and whilst it contains a selection of material gathered from a search of the evidence base, it is not intended to be comprehensive. International evidence focused on countries such as Australia, New Zealand, United States, and Ireland. From an r UK perspective, the evidence considered was mostly from England.
This summary is based on a rapid review of policy documents and websites in selected English-speaking countries on nursing roles and pathways to nursing careers. Searches of Google were conducted on the following key terms: accreditation of prior experiential learning; accreditation of prior learning; recognition of prior learning; widening access; routes of entry; flexible modes of entry; pathways; AND nursing/midwifery. In order to focus the results to countries of interest, country-specific Google sites were used ( https://www.google.com.au/, https://www.google.ca, etc). In addition, the websites of the nursing regulatory bodies in each country were checked individually for relevant policy documents.
Nurse roles and qualifications
Licensed practical nurses ( LPNs) and licensed vocational nurses ( LVNs) provide basic nursing care, under the direction of registered nurses and doctors. They must complete a state-approved educational programme (certificate or diploma), which typically takes about one year to complete. They must also be licensed through passing the relevant National Council Licensure Examination ( NCLEX- PN).  Registered nurses ( RNs) usually take one of three education paths: 
- a Bachelor of Science degree in nursing ( BSN)
- an associate's degree in nursing ( ADN)
- a diploma from an approved nursing programme.
Registered nurses also must be licensed, through passing the NCLEX- RN.
The Bachelor of Science in Nursing ( BS/ BSN) is a four-year degree offered at colleges and universities. The Associate Degree in Nursing ( ADN) is a two-year degree offered by community colleges and hospital-based schools of nursing that prepares individuals for a defined technical scope of practice. The Diploma in Nursing is available through hospital-based schools of nursing. It was once the most common route.  Licensed graduates of any of the three types of education programmes qualify for entry-level positions as a staff nurse, but some employers may request a bachelor's degree. 
An LPN may complete a LPN to RN education programme.  Those with diplomas or associate degrees may complete an RN to BSN programme or an RN to MSN programme. There are accelerated programmes for those who wish to enter the nursing profession and already hold a bachelor's degree in another field. 
The American Association of Colleges of Nursing published a position statement on 'Diversity, inclusion and equity in academic nursing' in March 2017. It stated that: 
'…realizing the benefits of diversity in the profession of nursing depends in part on expansion of the traditional pool of nursing school applicants … The measures of an applicant's readiness for nursing education and preparedness for practice should extend beyond reliance on specific quantitative data … Factors such as … ability to gain entrée into underserved communities, other transferable skills and abilities, and prior life experiences of individuals, may be relevant.'
One approach is the use of 'holistic review': 
'… a university admissions strategy that assesses an applicant's unique experiences alongside traditional measures of academic achievement such as grades and test scores. It is designed to help universities consider a broad range of factors reflecting the applicant's academic readiness, contribution to the incoming class, and potential for success both in school and later as a professional.'
According to a 2014 survey, only 47% of nursing schools in the US were using holistic review in their admissions, compared to 93% of dental schools and 91% of medical schools. 
Training programmes have been developed to help dental and medical schools develop mission-based holistic admissions processes, but similar training does not yet exist for schools of nursing. AACN and Urban Universities for HEALTH created a pilot workshop for nursing deans to address this need for education and training, held twice in 2016, with an associated online community of practice. 
In 2016, the Robert Wood Johnson Foundation produced a report on 'The changing face of nursing: creating a workforce for an increasingly diverse nation'.  It provided examples of initiatives to widen access to nursing careers, including:
- the use of holistic or whole-file review to overcome the barriers created by reliance on grade point averages ( GPAs) and standardised test scores, for example by the University of Illinois at Chicago ( UIC) College of Nursing, which adopted holistic review in 2013
- Nicole Wertheim College of Nursing & Health Sciences' initiative to expand the number of men and increase minority enrolment in its BSN degree programmes through:
- reaching out to occupational sectors that are predominantly male –veterans, paramedics and firefighters, and foreign-trained physicians
- creating accelerated programs to attract these potential candidates.
Nurse roles and qualifications
In Australia, an assistant in nursing ( AIN) works as a member of the nursing team and assists nurses to give general patient care. AINs need to complete a Certificate III in Health Service Assistance (a TAFE – Technical and Further Education – qualification). This can also be a pathway into a career in nursing or midwifery.
An enrolled nurse ( EN) is a second-level nurse who provides nursing care, working under the direction and supervision of a registered nurse. ENs need to complete an 18-month or two-year course at TAFE or related health facilities to achieve a Diploma in Enrolled Nursing. This can also be a pathway into a career in nursing or midwifery.
A registered nurse requires a Bachelor Degree in nursing.
Recognition of prior learning ( RPL)
The Australian Nursing and Midwifery Accreditation Council ( ANMAC) is responsible for the accreditation of all nursing and midwifery education providers and programmes of study in Australia.
ANMAC supports the principles of recognition of prior learning ( RPL) and credit transfer to facilitate the entry to and progression of students through nursing or midwifery qualifications (Bachelor of Nursing or Bachelor of Midwifery) by awarding credit for learning outcomes already achieved.  Prior learning can be formal or informal learning.
Credit transfer is defined in the Australian Qualifications Framework ( AQF) as:
'a process that provides students with agreed and consistent credit outcomes for components of a qualification based on identified equivalence in content and learning outcomes between matched qualifications.'
RPL is defined in the AQF as:
'an assessment process that involves assessment of an individual's relevant prior learning (including formal, informal and non-formal learning) to determine the credit outcomes of an individual application for credit.'
RPL may include previous formal learning, previous informal learning ( e.g. through work experience) and previous non-formal learning ( e.g. through a structured programme that doesn't lead to an accredited qualification).
ANMAC requires education providers to demonstrate that RPL and credit transfer are applied in an equitable, flexible, reliable and valid manner.
Health authorities and academic institutions encourage Aboriginal people into health careers through support and advice. Further information can be found at the following websites.
- the Western Australia Aboriginal pathways website 
- Career pathways for Aboriginal people in NSW Health 
- NSW Aboriginal nursing and midwifery cadetship program 
- The Congress of Aboriginal and Torres Strait Islander Nurses and Midwives ( CATSINaM). 
Nurse roles and qualifications
The Nursing Council of New Zealand ('Nursing Council') is responsible for the registration of nurses, including enrolled nurses and registered nurses. It prescribes the qualifications required, and accredits and monitors educational institutions and degrees, courses of studies, or programmes. Enrolled nurses are required to complete a Diploma in Enrolled Nursing. Registered nurses are required to complete a Bachelor Degree in nursing.
The Nursing Council stipulates  that each school must have a RPL policy and procedure against which to assess individual student applications. Prior learning may include qualifications, life experience, work experience or other educational experience.
The Mãori Health Workforce Development Unit ( MHWDU) at Otago University aims to support Mãori academic excellence in Health Sciences and increase the Mãori health workforce through a number of tailored programmes. Further information can be found at the following websites.
Nurse roles and qualifications
Registered practical nurses ( RPN) in Ontario and Quebec and Licensed Practical Nurses ( LPN) or Licensed Vocational Nurses ( LVN) in other Canadian provinces must 'graduate from an approved practical nursing program or equivalent'.  All Canadian provinces/territories (with the exception of Quebec) require a bachelor degree in nursing ( BN or BScN) to become an RN.
There is no national registration/license in Canada. There are separate regulatory authorities within each province and territory for each of the three regulated nursing professions – LPNs, RNs and registered psychiatric nurses – except in Ontario, where the College of Nurses of Ontario regulates both RPNs and RNs.  However, there is a Canadian Practical Nurse Registration Examination and Canada uses the US NCLEX- RN as the Canadian RN entry-to-practice exam.
In 2015, Nova Scotia published a report, 'Registered nurse education review in Nova Scotia', proposing a new model to improve undergraduate nursing in the province. The aims included to 'improve ability to transfer across programs and improve equity of access across the province'.
This included providing full recognition or specific block credit for prior learning.  The College of Licensed Practical Nurses of Nova Scotia provides regular updates on progress, with an LPN to BScN bridging programme. 
Education institutions in Canada recognise prior learning through Prior Learning Assessment and Recognition ( PLAR), which is described as: 
'a process that helps adult learners to identify, articulate and demonstrate relevant learning acquired through life and work experiences and translate this learning into college credit.'
Nurse roles and qualifications
Registered nurses are degree-educated and registered with An Bord Altranais/Nursing and Midwifery Board of Ireland ( NMBI).
The NMBI stipulates that HEIs should demonstrate 'a commitment to fair and transparent processes for student admission, entry, transfer, discontinuation and completion'. Indicators to demonstrate this commitment include: 
'Flexible modes of entry – for example mature students, FETAC, access, graduate entry – and clear procedures for Approval of Prior Learning ( APL) are specified and have been approved by NMBI.'
Nurse roles and qualifications
Care assistants have no registration or fixed title, although a care certificate was introduced in March 2015. Registered Nurses are degree-educated, registered with the Nursing and Midwifery Council.
The Willis report's recommendations included: 
- Health Education England ( HEE) should evaluate the impact of the care certificate (introduced March 2015) and, subject to the evaluation, government should ensure that it is a mandatory requirement
- NHS England should agree titles and job descriptions that align with HEE's development of a career and education framework for care assistants
- care assistants should be offered APEL that could account for up to 50% of the undergraduate nursing degree
- HEE, in collaboration with employers and HEIs, should support the development of more innovative work-based learning routes.
In December 2015, the UK Government announced a plan to create a new nursing support role – nursing associates – that will be regulated by the NMC. The role is intended to help bridge the gap between healthcare support workers, who have a care certificate, and registered nurses. It is intended that it could also be a new route for those wishing to become a registered nurse. 
In November 2016, the UK Government announced the introduction of nursing degree apprenticeships. Apprentices will be released by their employer to study part-time in a higher education institution and will train in a range of practice placement settings.  They are expected to begin in September 2017.
The NMC provided guidance to nurse education providers on accreditation of prior learning ( APL) in circular 01/2011 and its annexe. 
Mature students have the benefit of life experience, emotional maturity and intrinsic motivation and have the potential to be a sustainable workforce as they tend to work locally and stay in the profession longer. However, many have life commitments but are expected to fit into existing programmes that have limited flexibility. Part-time programmes may be an option for potential students who cannot commit to a full-time conventional programme.
Draper et al. conducted a qualitative study to explore the impact of the Open University's pre-registration programme on students' employability, career progression and contribution to the UK workforce. Alumni (n=17) and employers (7) were interviewed >2 years post qualification. Themes identified included transition, expectations and learning for and in practice, and flexibility. Employers found the part-time programme provided the flexibility to grow their own workforce. Alumni reported that it provided them the opportunity to achieve their ambitions which could not have been achieved through conventional routes due to personal circumstances.
Implications for the project arising from this rapid review include:
- the development of clear definitions of the target groups for widening access to pre-registration nursing and midwifery programmes are required to influence recruitment strategies
- mapping of the current access routes to pre-registration nursing and midwifery programmes
- a review of alternative entry qualifications and admission processes of HEIs
- an understanding of the current provision of flexible/non-conventional programmes ( e.g. part-time).