The RCN is providing a range of papers to aid understanding and contribution to the Modernising Nursing Careers (MNC) initiative. This paper provides some reflections on this agenda, an interpretation of the drivers for change in the nursing profession and a vision for future nursing structures, career pathways and educational approaches. It is important to emphasise that these are personal reflections and observations and are designed to provoke discussion and debate. However the underlying belief is that the profession must bite the bullet and embrace radical change without delay. This is essential if nursing is to be fit for purpose in the coming decades.