Unsafe conditions due to nursing shortages in the health and care sector have "normalised" and there is little sign that the workforce crisis is improving, nursing leaders have warned.

In its third annual report on the nursing workforce in Scotland, the Royal College of Nursing (RCN) cautioned that there is a "significant" risk of patients coming to harm as nursing vacancies are filled by less qualified staff.

It found that Scotland has fewer nurses per head compared to the UK as a whole, and lags well behind nations including Ireland, Norway and Finland for nursing numbers.

Changing demographics were also highlighted, with more than 23% of staff in mental health nursing now aged 55 or over - up from less than 8% a decade ago.

A quarter of those in working in learning disability nursing are over 55, as are a third of those in health visiting.


The report stressed that the retirement was not the only factor leading to increased turnover, however, adding that increases in the number of nurses leaving the NHS in Scotland has continued during 2023 "in every age group including increasing numbers in their twenties, thirties and forties".

It noted that while the number of registered nurses in post in Scotland has increased by 7.8% over the past five years, this is exceeded by a 20.5% increase in the number of nursing support workers.

This includes a 53% increase in nursing support workers within district nursing, a 19% increase within adult nursing, and a 13% increase within mental health nursing.

The report states that the "continued failure to retain and recruit sufficient numbers of registered nurses to meet the growing demands and complexity of health and social care is impacting on the ability to provide safe, high-quality care".

The Herald: Nursing support worker numbers are increasing much faster than registered nurse numbersNursing support worker numbers are increasing much faster than registered nurse numbers (Image: RCN)

It pointed to studies showing that every patient added to a registered nurse's workload is associated with a 7% increase in mortality, and that substituting a registered nurse with a nursing support worker is associated with a 21% increase in mortality.

It adds: "The substitution of registered nurses happens when employers in both the NHS and independent sector struggle to fill gaps in their registered nursing workforce.

"Employers resort to simply changing the level of the vacant registered nurse post to that of nursing support worker.

"Within NHS Scotland there has been a growth in the number of nursing staff but over the last three years this has been largely due to the growth in nursing support worker roles, including the new Band 4 assistant practitioner roles."

While these roles were "a vital part of the nursing workforce", the RCN stressed that they have "different levels of experience and qualifications" compared to a registered nurse and "should never be pressured to work beyond their competencies or scope".

The report states: "Developing new roles such as assistant practitioners and nursing associates should not be taken lightly. We highlighted last year that their purpose should be clearly defined before introduction.

"The risk of patients receiving substandard care – resulting in direct or indirect harm – is significant.

"There should be no possibility of inappropriate role substitution with the introduction of new roles in either health or social care."

The Herald: Scotland has fewer nurses per head than the UK as a whole, but more than EnglandScotland has fewer nurses per head than the UK as a whole, but more than England (Image: RCN/OECD)

An analysis included in the report found that there were 7.9 nurses per 1,000 population in Scotland, compared to the OECD average of 9.2, and roughly 8.2 for the UK as a whole.

In Ireland, the figure was around 15, rising to 18 and 19 per 1000 respectively in Norway and Finland.

Colin Poolman, RCN Scotland Director, said: “Nurses and nursing support workers across Scotland are under paid, under-staffed and many are at breaking point.

"The current service pressures and staff shortages have resulted in unsafe conditions being normalised.

“We have said it before and we will continue to say it - the future looks bleak if the Scottish Government does not grasp with both hands the opportunity for improvement the Ministerial Nursing and Midwifery Taskforce and Agenda for Change review present to alleviate the workforce crisis."

Mr Poolman also urged ministers to "move swiftly to open negotiations for the 2024-25 NHS Scotland pay award".

The report sets out 10 recommendations to address "stubbornly high" nursing vacancies and retention, including fair pay, improved terms and conditions, and an evaluation and annual parliamentary debate on the recently implemented safe staffing legislation.

The Herald: There has been a substantial increase in the number of nurses leaving the profession in ScotlandThere has been a substantial increase in the number of nurses leaving the profession in Scotland (Image: RCN)

Julie Lamberth, chair of the RCN Scotland Board, said: “The picture this year’s report paints is simply not sustainable nor is it in the interests of patients and service users.

“At no point has NHS Scotland employed the number of nursing staff it says it needs to deliver safe care and the registered nurse to resident ratio in many care homes makes safe care impossible.

“At the same time, with the squeeze on budgets, we are hearing reports of nursing roles being axed.

“The Scottish Government must get serious about the workforce crisis and the long-term implications for the public’s health.

"Nursing vacancies are having a damaging impact on our members ability to provide safe and effective care.

"And on their own wellbeing when shift after shift they work extra unpaid hours to cover gaps and go home feeling that they are unable to provide the quality of care they want.”

Health Secretary Neil Gray said nurses in Scotland remained the highest paid in the UK and eligible nursing and midwifery students also had access to the highest non-repayable, non-means tested bursaries of £10,000.

He added: "I know that more needs to be done to recruit and retain our valuable workforce and that is why I am Chair of the Nursing and Midwifery Taskforce which aims to build on efforts to make Scotland the best place for nurses and midwives to come to work.

“The taskforce brings together stakeholders representing all aspects of nursing and midwifery across Scotland, including [High Education Institutions], the RCN and RCM, working collaboratively to identify recommended actions to form the output of the Taskforce. 

"The RCN is fully engaged with this work and will be helping to shape the final recommendations for the Taskforce.

“Whilst there is a lot of work already underway to support a sustainable and skilled workforce, the Taskforce will help us identify gaps and prioritise work, focusing on tangible outcomes that will futureproof our workforce in light of the ongoing demands that our services face.”