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RCN position on registered nurse substitution with nursing support workers

Published: 24 June 2026
Last updated: 24 June 2026
Abstract: RCN position on registered nurse substitution with nursing support workers

The level of registered nurse (RN) staffing is critical to patient safety, the prevention of avoidable harm, and the management of risks, regardless of the location or situation.

There is clear evidence that substituting RNs with support staff carries risk to patients, and there is no evidence to support the view that substitution is safe or cost effective (Dall’ora and Griffiths, 2026).

The RCN expects all employers, regardless of sector, to have developed robust nursing workforce plans, in line with the RCN’s Nursing Workforce Standards. The RCN’s position is that when evidence-based workforce planning identifies the need for an RN, substitution is not an option, and this should apply across any setting.

All UK governments should base workforce planning on population need as a first principle. Investment and reform in health and social care is needed to meet population health and care needs. Investment in nursing must ensure that RNs across all sectors and settings are leading nursing care.


Evidence of the impact of registered nurse substitution

Evidence shows that lower RN staffing increases patient harm and reduces care quality. As highlighted in the College’s position statement, the link between RN staffing levels and mortality is well established, with low RN staffing also associated with higher levels of missed care, directly affecting patient safety, experience and satisfaction. The risks of low RN staffing cannot be mitigated by having more support staff.

Nursing support workers make a vital and valued contribution to patient care. They strengthen teams, improve continuity and provide essential hands-on support. However, their role is complementary, not interchangeable with that of RNs. RNs have expertise in advanced clinical judgement, risk assessment and decision-making skills that support workers are not trained or authorised to perform.

Reducing RN levels by replacing them with support staff increases risk of higher mortality, more adverse events, increased missed care, and greater RN burnout, dissatisfaction and turnover. Importantly, these models do not save money, as poorer outcomes lead to longer stays, higher readmission rates and higher system costs (Griffiths et al 2023, 2025, 2026; Dall’ora and Griffiths et al, 2026).

The interaction between RN and support worker staffing is complex. Research shows that mortality increases when support worker staffing is either too high or too low. Very low levels shift additional tasks to RNs, reducing the time available for assessment and monitoring (Griffiths et al 2019). Both scenarios compromise safety and highlight the importance of a balanced, evidence-based skill mix.


Conclusion

Substituting RNs with nursing support workers is unsafe, ineffective and economically counterproductive. Governments, employers, and regulators must commit to evidence-based workforce planning that values the critical expertise of RNs, and focusses on the long-term demand for services, patient safety and workforce wellbeing across all sectors and settings.

RNs are crucial to nursing leadership, education, practice and research.

Evidence clearly shows that RN substitution with nursing support workers is not a solution to workforce shortages, and reducing RN staffing levels in clinical practice threatens patient safety.


References

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