Introduction

Nursing is a safety-critical profession founded on four pillars: clinical practice, education, research and leadership. Registered nurses use evidence-based knowledge, professional and clinical judgment to assess, plan, implement and evaluate high-quality person-centred nursing care. Registered nurses are key to the delivery of safe and effective population health, care and wellbeing. They lead nursing teams and work collaboratively with other health care professionals.

RCN Position

A registered nurse must never be substituted with any other health care professionals including nursing support workers (which includes registered nursing associates). There is evidence that substitution can have a negative impact on the quality and safety of the nursing care being delivered.

All employers working within health and social care must ensure that where a vacancy exists for a registered nurse, this is open to registered nurse applicants only. The RCN expects all employers, regardless of sector, to have developed robust nursing workforce plans, in line with the RCN’s Nursing Workforce Standards.

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 registered nurses are leading nursing care.

Evidence of the impact of registered nurse substitution

The education and training that registered nurses receive ensures that they have the right knowledge, skills and attitudes to effectively lead holistic nursing care for their patients and service users. The evidence that links registered nurse staffing levels and patient safety including mortality is well established. Lower registered nurse staffing levels are associated with higher risks to patients and poorer quality care. The evidence shows an increased incidence of missed care which is known to have a negative impact on patient safety and satisfaction. The Francis Report clearly demonstrated the catastrophic risk of having an inadequate number of registered nurses.

There is an international evidence base from the acute hospital setting which shows that attempts to substitute registered nurses with less qualified personnel such as nursing associates and nursing assistants can increase adverse patient outcomes, is associated with greater nurse burnout, dissatisfaction, and turnover, and does not save money.

Evidence of registered nurse substitution

The Royal College of Nursing (RCN) has seen an increase in the number of occasions where positions requiring a registered nurse are being advertised from Band 5 up to Associate Director of Nursing level with an indication that other registered health care professionals can apply.

In England, Band 5 roles for registered nurses are now appearing as open to nursing associates as well as other professionals registered with the Health and Care Professions Council. The position of the registered nursing associate is specifically intended to assist the role of the registered nurse. A registered nursing associate should never be used as a substitute because a registered nurse post cannot be filled.

Many inquiries and reviews have stressed the importance of nurse leadership and there is evidence that this has a significant impact in two main areas: patient experience and outcomes, and nurse satisfaction and retention. The RCN challenges the perception that an Allied Health Professional (AHP) matron can provide nursing supervision and leadership. An AHP matron may be able to provide the management function, but this is only part of the registered nurse matron role. They are not ‘equivalent’, just as a registered nurse would not be equivalent to a registered AHP.

Moreover, the use of titles such as Matron, or Ward Sister/Charge Nurse by those who are not registered nurses can be misleading for patients and their carers in the attribution of knowledge or skills to the post holder that they do not in fact possess. This is also the case in the independent health and social care sector e.g. care homes with nursing.

We have also seen examples of where in England, Physician Associates have been recruited into roles that enhanced-level registered nurses hold. Examples are, in primary and community care for long-term conditions and in nurse specialist roles such as respiratory and diabetes.

There are reports of student nurses being used to cover staffing gaps in practice. All pre-registration nursing students must be 100% supernumerary whilst on placement.

The known recruitment and retention crisis

The numbers from the NMC register (released at the end of 2024 covering Oct 2023 to Sep 2024) indicate a growth of around 57,000 new joiners. However, the growth rate has slowed. UK-trained joiners have plateaued, showing no real increase. A 5% drop in non-EU/EEA international joiners compared to 2022/23 is significant given the UK's reliance on overseas-trained professionals.

An ageing workforce is also a concern with 18% of the register (over 150,000 professionals) are aged 56–65 and nearing retirement. Vacancy rates remain stubbornly high with over 27,000 vacancies in NHS England alone and around 35,000 UK-wide. UCAS data shows a 22% drop in applications and a 19% drop in acceptances since 2021.

This suggests a shrinking pipeline of future nurses. There is a mismatch between demand and supply. A rising patient numbers with more complex needs whilst workforce planning has not kept pace with population health demands.

Conclusion

The answer to shortages of registered nurses in the workforce is not substitution but rather significant and sustained investment in nursing, strengthening the domestic supply of the registered nurse to meet future need. Workforce planning at the national and local level must focus on the demand for nursing services, patient safety and workforce wellbeing across all sectors and settings.