The Nursing and Midwifery Council’s (NMC) newest protected title reached its first major milestone when the 1,000th nursing associate joined the register in June. With Health Education England (HEE) ramping up recruitment this year, the role is only set to grow. To analyse its impact so far and potential to contribute to the profession, Nursing in Practice spoke to a variety of stakeholders, including nursing associates, academics and policy makers.
Nursing associates – who predominantly have a support worker background – have expressed positive views about the new opportunities the role offers them, and speaking to Nursing in Practice, HEE chief nurse* Lisa Bayliss-Pratt was as enthusiastic as when she introduced the title in 2016: ‘It’s the right thing to be doing for the individual, the profession and most importantly the patients they look after’. But not everyone is so convinced.
Rolling the dice
The suspicion that nursing associates might be exploited as a cheap substitute for nurses has plagued the role since its inception. In the current climate of 40,000 nursing posts unfilled in the NHS in England alone, Professor Jane Ball, a nurse staffing and workforce policy researcher at the University of Southampton, is concerned that nursing associates might be used to substitute nurses rather than support them as intended. ‘Diluting the workforce so that you’re replacing registered nurses with less-qualified staff risks patient safety and the quality of care,’ she says.
Professor Ball is open to a cheaper, less-educated workforce if it has no impact on patient safety, but finds the possibility ‘highly unlikely’. She is worried that nursing supply ‘has been so poorly judged and insufficient’ for so many years it creates an ‘understandable desperation’, where an employer might say: “What if we had some less-skilled nurses instead, surely something is better than nothing?” She continues: ‘As an academic looking inwards from the outside, it appears there’s insufficient caution and care in how this new role is being introduced and in thinking through what the consequences might be.’
To be certain of its impact, Professor Ball is calling for an independent evaluation of the nursing associate role. ‘I’d like to have hard data,’ she says, which she proposes should include the posts that nursing associates are going into and any resulting changes to the skill mix. ‘Without that evaluation, we’re just rolling the dice.’
HEE has commissioned research organisation Traverse to evaluate the role. Phase one, which was published in 2018, found high levels of enthusiasm among trainees but a ‘limited understanding’ among healthcare staff. Phase two is expected to be published this year. But Professor Ball says the evaluation focuses too much on the trainee role rather than properly measuring the impact of nursing associates on the skill mix of the workforce and patient safety.
Fiona McQueen, chief nursing officer for Scotland, has indicated she is also concerned. In August 2018, Professor Ball tweeted her worry that registered nurses are being replaced with nursing associates and Ms McQueen’s reply was damning: ‘Agreed – in Scotland, the impact of graduate-level nursing is recognised. The nursing associate role will not be in place in Scotland.’ England remains the only country to have introduced the role.
‘We’ve definitely got more jobs than nurses,’ Ms Bayliss-Pratt acknowledges. In terms of protective measures, she cites safe staffing regulations and Care Quality Commission inspections, saying that patients are ‘more informed’ than ever. ‘But I don’t think people are in that position of swapping one for the other,’ she adds. ‘I see that nursing associates are going into places where registered nurses have never been, and then registered nurses are being enabled to develop and grow and become more senior because they’ve got this educated workforce wrapped around them.’
There’s a lot of talent out there
Ms Bayliss-Pratt argues that ‘there’s room for everyone’ in the workforce, referring to both nurses and registered nursing associates. This belief falls in line with one of the aspects that she says excites her most about the role: ‘There’s massive untapped talent out there in the support workforce – I think there’s more work to do on preparing the support workforce to become trainee nursing associates.’
Not only can support workers gain additional skills through becoming a nursing associate, it also enables them to become a nurse through a shortened programme. Creating this stepping stone for support workers is deep-rooted in the role’s origins, says Ms Bayliss-Pratt. The idea emerged from the HEE’s ‘Shape of Caring’ review, published in 2015, which recommended the removal of barriers to help support workers enter the professions, such as nursing.
Ms Bayliss-Pratt believes the nursing associate role is now helping to address this ‘massive gap’. She says that for many support workers, becoming a nurse would have previously been impossible: ‘They would not be able to go from the support worker to our undergraduate student nurse. There’s shedloads of talent and potential out there that – up until this role – has gone unrecognised in the main.’
If you ask a room full of nursing associates whether they want to become a nurse, 80% normally raise their hand, says Ms Bayliss-Pratt. Realistically, however, she expects 40-50% of cohorts to go into nursing, especially if some begin to feel fulfilled and comfortable enough in the nursing associate role to no longer want to become a registered nurse. According to Government estimations, the new route is expected to result in around 4,600 extra nurses by 2022.
Understanding the role
If asked by HEE whether she wants to become a nurse, Michelle Alderson would undoubtedly join the raised hands in the room. The trainee nursing associate, who works at a social care facility in Bristol, had previously struggled to get funding for a nursing degree and worried about no longer earning. But the new route offered an alternative.
On her contribution to the team, Ms Alderson told Nursing in Practice: ‘I can see how I’m an asset to the nurses, and I can see how I’ve moved away from the healthcare assistant role.’ But some colleagues question whether she should carry out certain tasks, even if cleared to perform them by her employer. ‘I’d be doing catheters and they’d say to me, “Well, a student nurse can only do this kind of catheter,” and I’d say, “Yes, but I’m not a student nurse!”’
The nursing associate role is regulated, meaning they must complete revalidation and fitness to practice requirements. Once she graduates, Ms Alderson says getting a PIN from the NMC will help protect her from unwanted questions about her scope of practice. ‘I’m risking my PIN if I do something wrong,’ she explains. ‘I have to do everything [my employer] allows me to do and nothing more. I have to know what my parameters are. If I overstep that mark, I have only myself to blame.’
Ms Bayliss-Pratt says nursing associates and their employers should discuss scope of practice, as this will vary between clinical environments. Needing to gain clarity around a relatively unknown role is a common scenario, she adds, comparing it to conversations about the remit of a newly qualified nurse or an advanced practitioner. ‘I think the more nursing associates we have, and the more they become part of the workforce, the easier that will be.’
She continues: ‘Where we’ve got nursing associates working with registered nurses, they absolutely love them. Where we haven’t got those teams yet, there’s a bit of scepticism or lack of clarity around, “What will this role do? How will it work?”’ She says HEE must make sure the role is properly communicated: ‘We’ve got to speak to leaders in the clinical fields about this role and ensure they understand exactly what the role is, what it does and how it adds value.’
Ms Bayliss-Pratt argues that the generalist nature of the role means it adds extra value to the nursing team: ‘[Nursing associates] get experience in acute settings, in primary care, in mental health settings, in social care settings and, as a result, what we’re hearing… is how holistic their care delivery is because they’ve had exposure to all these different things.’
Sherwin Brown, a nursing associate in the home treatment team at South West London and St George’s Mental Health NHS Trust, agrees that the role allows support workers to offer more: ‘As a support worker, I had limitations. Now as nursing associate, I still have limitations, but I can do more in terms of understanding physical health, patient deterioration, medication and all sorts. It’s really enhanced my ability.’
It also benefits the whole nursing team, he says, as nursing associates enter the workplace with ‘mixed’ physical and mental skills, and ‘we can refresh someone’s mind’. In what is particularly helpful for his work, Mr Brown has now studied mental health. ‘I understand more so I know how to refer [patients] to a different unit to get a help,’ he says, using the example of a person with drug or alcohol problems.
Mr Brown is not alone in pushing the value of the nursing associate as a standalone role. For Alicia Langdown, a trainee nursing associate at a general practice in Dorset, the role was initially nothing more than a path from healthcare assistant to nurse. But, she told Nursing in Practice, as the course progressed, she saw the role as more worthy in its own right: ‘I now feel I want to be a registered nursing associate to consolidate my learning and to promote the role. I may continue with my training to become a registered nurse, but being a nursing associate is no longer just a stepping stone.’
She continues: ‘I don’t consider myself a cheap nurse and I respect the registered nurses completely, the responsibility placed on their shoulders has grown over the years and they are now doing tasks that doctors would have had to do a few years ago. As they grow in their jobs, so will the nursing associate role.’
A frustration for Ms Langdown is that the public do not understand the value of the role: ‘The first nursing associates went on the register in January this year and it wasn’t big news in the papers or on TV. This should have been handled differently to allow the public the chance to get to know the role and how we can enhance their experience in the NHS.’
Clare Mechen, a nurse who works with Ms Langdown and supported her to become a nursing associate, thinks that nursing associates are not a threat to nurses – quite the opposite: ‘I believe the role will become an integral part
of the future primary care nursing team. They will be able to support the registered nurses to deliver the wide variety of care we undertake and support demand in general practice. Like most changes in healthcare, it will take time to develop.’
To any nurses concerned about the nursing associate role, she says: ‘I can appreciate there may be some in primary care nursing who may see nursing associates as a threat and deem them as a cheap substitute, but they should be seen as an enhancement to the workforce. Often, I hear how busy everyone is in practice, so why not encompass new roles – there is certainly enough work in primary care for everyone.’
*Lisa Bayliss-Pratt is taking a six-month secondment as pro vice-chancellor at the University of Coventry. Professor Mark Radford, currently deputy chief nursing officer for NHS England and NHS Improvement, will be joining HEE on secondment as chief nurse as of 1 October.