Nursing associates are being offered places on a university programme typically designed for registered nurses who are new to general practice – adding weight to ongoing concerns over role substitution.
It has come to light that NHS England (NHSE) is funding nursing associates to carry out a Level 6 Foundation course for newly registered nurses or registered nurses new to employment in general practice in some London universities.
However, key stakeholders have raised concerns relating both to the safety of patients and nursing associates themselves.
Nursing associates were introduced in England in 2019 and were designed to bridge the gap between healthcare assistants and registered nurses. Plans have recently been announced for the role to be introduced to the NHS in Wales.
In recent months, concerns have been increasingly raised around GPNs in England being substituted by nursing associates – a role practices can claim funding for under the Additional Roles Reimbursement Scheme.
NHSE funding for nursing associates
Guidance from NHSE on general practice nursing training programmes for 2023/24 – that started in Autumn 2023 or January 2024 – sets out information and funding arrangements for training hubs and general practices on both a Foundation and Advanced version of the training. These courses are typically known as Fundamentals for General Practice Nursing.
It states that the Level 6/7 Foundation programme will be available at six higher education institutions (HEIs) in London and will ‘broadly offer “start-up” skills-based training for newly qualified nurses and/or nurses new to employment in general practice’.
On completion of the course, NHSE states that general practice nurses (GPNs) ‘will have gained skills in a number of areas, including cervical sampling, childhood immunisations and travel vaccinations and will be ready to work autonomously as part of the general practice team’.
However, the guidance goes on to add: ‘Please note we will also fund nursing associates on the Level 6 Foundation course’.
‘Sending the wrong message’
Chief executive of the Queen’s Nursing Institute Dr Crystal Oldman warned the approach would ‘exploit’ nursing associates and send the wrong message to their employers.
She told Nursing in Practice her organisation was ‘increasingly concerned by the substitution of registered nurses, who are employed in general practice, by nursing associates’.
And she is concerned that offering these programmes to nursing associates, will impact both the workforce and patient safety.
‘Offering an identical programme with the same learning outcomes, the same content and assessment at the same academic level for two groups of professionals whose preparation for initial registration with the NMC, clinical responsibilities, supervision requirements and accountability in practice is very different, is a flawed approach to professional nurse education,’ argued Dr Oldman.
‘Nursing associates can fulfil a really valuable role in the general practice team.
‘However, this approach to their preparation for the role sends a clear message to their employers – our general practitioner colleagues – that nursing associates can be prepared for a nursing role in general practice and employed in an identical way to the preparation for registered nurses and can therefore be a substitute for the registered nurse.’
She added: ‘It is unfair to the nursing associates to exploit them in this way and most importantly, introduces a risk to patient safety.’
‘It puts their PIN at risk’
Su Hickman, senior clinical trainer in health and social care and a registered nursing associate, feared the move would make nursing associates ‘vulnerable’.
‘I am all for nursing associates furthering their study and progressing. However, this is quite concerning to me,’ she told Nursing in Practice.
‘I think it has come from a place of good intention and they want to give the nursing associates a chance to further their education.
‘However, I would never even think of applying to this course unless I had done the [registered nurse] top-up.’
She added: ‘My nursing associate foundation degree does not prepare me to get a postgraduate certificate in general practice nursing and it’s going to be open to abuse and exploitation.’
It was Ms Hickman’s view that these programmes ‘should not be offered to a nursing associate’.
‘It puts them out of their scope of practice, it makes them vulnerable, and it puts their PIN at risk.’
Practice differences ‘repeatedly stressed’
Nursing in Practice has attempted to contact all six HEIs listed in the guidance but has only received responses from four.
Shaun Heath, senior lecturer at the University of Greenwich, confirmed the university ‘does allow’ nursing associates to complete its Fundamentals in General Practice Nursing course.
‘They are allowed to complete the skills-based course at Level 6,’ he said.
Mr Heath described the Level 6 programme as ‘an introductory course for the nursing family to work in primary care’ and that it was ‘stressed repeatedly throughout our module the differences between leading and managing care, as opposed to, contributing and the delivery of care, alongside the need to utilise PSDs versus PGDs’.
The course also covered ‘introductory elements to long-term conditions, primary care (commissioning, contracts and structure), as well as cytology and immunisation’.
He added: ‘I have not been aware of GPNs or nursing associates being asked to work out of scope of practice, but if this is the case, I would question the GPNs/nursing associate’s understanding of the Nursing and Midwifery Council Code.’
Meanwhile, Buckinghamshire New University (BNU), which advertises its Fundamentals in Primary Care programme to both registered nurses and nursing associates, told Nursing in Practice that nursing associates were able to access only two modules of the programme.
Karen Buckwell-Nutt, director of the Institute for Health and Social Care at BNU, said the graduate certificate for the GPN course could only be achieved fully by registered nurses.
‘However, to support the local workforce, nursing associates can study two modules worth 30 CPD credits each from this course in line with their professional code of practice, should they wish to upskill and develop their knowledge: management of long-term conditions for healthcare professionals; and clinical skills for healthcare professionals in primary care.
‘We have a very small number of NAs taking up these modules relative to the number of GPNs on the Fundamentals programme.’
On its advert for the course, BNU states nursing associates should ‘undertake the programme at Level 6’ and that registered nurses ‘may choose between Level 6 and 7’.
In addition, the advert also claims those on the programme need a ‘named supervisor’ which could either be ‘an experienced nurse or nursing associate’.
Meanwhile, Kingston University said it was ‘not currently running’ the GPN fundamentals course, despite a proposed start date of 15 January and the University of West London confirmed it did not offer its Foundation general practice nursing course to nursing associates.
The other HEIs listed by NHSE as delivering a GPN course which could receive funding for nursing associates – the University of Hertfordshire and City, University of London – did not respond.
Responding to the concerns raised, an NHS spokesperson said: ‘Developing the general practice nursing workforce and offering a range of career progression opportunities are crucial elements of the NHS Long Term Workforce Plan.
‘We work with higher education institutions across England to find the best approach depending on demand and service pressures, with HEIs having the final say over entry requirements.’
