Workforce planning and development are big business. There are many involved at a strategic level nationally, regionally and locally to ensure that we recruit and retain sufficient staff to deliver high-quality, person-centred care. Yet despite this, there is a serious national shortage of nurses. The Government in England and the nursing profession are having to think creatively to tackle the workforce challenges. They are doing so not only to support the ideals of person-centred, compassionate and evidence-based care but to address the health promotion and public health issues that Wanless1 warned us to heed, in order to prevent the burden of avoidable illness.
While the community workforce has generally increased by more than 30% over the past 10 years, 60% of hands-on care is delivered by non-registered support workers.2 Although it is clear that nursing assistants are a crucial part of the healthcare workforce, the Cavendish review3 reports them as feeling undervalued and overlooked. However, numbers only represent half of the story. Understanding the skill mix required in the community is essential to ensure safe and effective care where patients are empowered to take more responsibility for their treatment and staff are given time to care.
On 17 December 2015, the government in England announced the introduction of the new role of nursing associate (the title is yet to be confirmed). Then, at the end of January 2016, Health Education England began consultations with the profession, with the promise of a report in June 2016. This report will make recommendations on the title and feasibility of this new role, the expectations, education and preparation and whether it should be regulated.
So, what is a nursing associate? With the ongoing radical change required by the NHS and the necessity to deliver greater levels of out-of-hospital care, a new role is needed. The nursing associate offers a higher skillset than the current nursing assistant and will give greater support to the registered nurse (RN). In principle this sounds reasonable. However, we must ask ourselves: what will be the difference between the new nursing associate and the existing assistant practitioner role? And how will it differ from the now obsolete enrolled nurse? Are we in danger of revisiting the mistakes of the past? Will the nursing associate feel just as undervalued as the existing assistant workforce? Will the role become marginalised with little or no investment? It is worth considering the differences in turn.
Nursing associate vs assistant practitioner
As I see it, the difference between the new nursing associate and the current assistant practitioner is that the assistant practitioner is a role that spans professional boundaries. Both of the roles will be graded as Agenda for Change Band 4,4 however the assistant practitioner will focus particularly on nursing, thus complementing nurses’ work.
The assistant practitioner will be specifically educated with the knowledge and skills of nursing to supplement the role of the RN, and support the nursing leadership in the delivery of high-quality person-centred care.
It is anticipated that both roles will be educated through an apprenticeship model to foundation degree or equivalent, so they will both have higher levels of knowledge and critical thinking skills than healthcare assistants. Additionally, they will be prepared with higher skills and competence than nursing assistants (Bands 2 and 3)4 and will contribute to the vision articulated in the Five Year Forward View.5
The nursing associate vs enrolled nurse
Unlike the enrolled nurse, the nursing associate role is linked to the first two years of the RN programme. Therefore nursing associates will have the option to progress to RNs by accrediting their learning and competence against the undergraduate programme. Career progression was not a feature of the enrolled nurse role. They were an able part of the nursing workforce, yet were prevented from developing except by a bespoke ‘conversion’ to registration.
The nursing associate role will offer greater flexibility to the nursing workforce. With a clearly defined practice and education pathway, it will support the professions’ capability to deliver high quality care. With the move to an all-graduate intake for students wishing to become RNs, there are likely to be able individuals with the potential to succeed at foundation degree level and remain in a more senior role than a nursing aide, or progress to registration at a slower pace than the graduate programme requires. This new approach would serve the profession well and offer opportunities for those unsure of their academic ability who nevertheless wish to enter at a higher level than a healthcare assistant.
The one area the profession needs to consider is whether this role, which is more advanced than the healthcare assistant, should be regulated. The enrolled nurse role was regulated by the Nursing and Midwifery Council (NMC).
Formal regulation would offer a level of public protection. Lord Willis in his Shape of Caring review2 strongly supports regulation for this level of practitioner but it is something that we in the profession need to influence and we await the recommendations. Most importantly, however, is the need for RNs, as leaders of care, to recognise the importance of our workforce at all levels and to invest in it. We each have a responsibility to recognise good practice and reward it, both by praising our colleagues when we see good care but also by investing in their education and training to support their career progression and raise morale.
RNs play an important role in community services. Given the predominance of autonomous practice within primary care, RNs will be required to develop a range of advanced practice skills such as prescribing, diagnostic reasoning and complex pain relief interventions,2 fairly soon after qualifying. This will impact on the need for a skilled associate workforce that will be able to plan and deliver care for people in their own homes with complex long-term conditions, and who require a level of intensity that was previously managed in the acute care sector. The nursing associate will be well placed to work differently, supporting the registered nursing workforce through the use of digital technologies, new ways of working and new models of integrated care.
If we as the profession have accepted the nursing associate through the consultation, we need to embrace the role, support our colleagues and, through collective leadership, empower our teams with the confidence to enhance the quality of care and to challenge appropriately.
1. Wanless D. Securing Our Future Health: Taking a long-term view, 2002. HM Treasury. si.easp.es/derechosciudadania/wp-content/uploads/2009/10/4.Informe-Wanless.pdf (accessed 15 April 2016).
2. Willis R. Raising the bar: shape of caring: a review of the future education ad training of registered nurses and care assistants. hee.nhs.uk/sites/default/files/documents/2348-Shape-of-caring-review-FINAL_0.pdf (accessed 15 April 2016).
3. Cavendish C. The Cavendish Review: An independent review into healthcare assistants and support workers in the NHS and social care setting. gov.uk/government/uploads/system/uploads/attachment_data/file/236212/Cavendish_Review.pdf (accessed 15 April 2016).
4. Health Education England. Agenda for change – pay rates. healthcareers.nhs.uk/about/careers-nhs/nhs-pay-and-benefits/agenda-change-pay-rates (accessed 15 April 2016).
5. NHS England. Five Year Forward View, 2014. england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed 15 April 2016).