The term ’nursing support worker’ encompasses hundreds of different job titles and roles, including:

• health care assistants (HCAs)
• health care support workers (HCSWs)
• assistant practitioners (APs)
• maternity support workers (MSWs)
• nursing assistants
• nursing associates (NAs) (England)

Here at the RCN, we’re concerned about increasing examples of inappropriate deployment of this workforce.

We’ve produced this guide for employers to promote consistency in safe practice.

As a member of nursing staff, you can share this guide with your employer if you believe they are using the nursing support workforce inappropriately where you work.

If you’re a manager, use this guide to ensure you’re appropriately deploying and valuing nursing support workers.

We’ve undertaken work to define the remit and responsibilities of the Nursing Support workforce to protect nursing staff, their employers and the public by ensuring a consistent approach and shared understanding.

This work relates to the support workforce that is supervised by a registered nurse. We acknowledge that a broader group of support workers exists across health and social care settings, often referred to as health and social care support workers.

Nursing support workers are valued, collaborative members of nursing and multidisciplinary teams, providing person-centred nursing care across health, social care and education settings.

While they are responsible for their own actions, all nursing care they deliver is delegated and supervised by a registered nurse. Their role supports and assists registered nurses in delivering safe and effective care for individuals and populations.

Expert consensus has identified two distinct levels within the nursing support workforce:

Supportive: Includes health care assistants, health care support workers and equivalent roles in all settings.

They will work within the team under the supervision of a registered nurse, delivering delegated task orientated care consisting of routine, high-volume activities with little variance. They have knowledge and understanding within the nursing support worker context, developed by education and training to the standard set for this level by the country of employment within the UK. They are responsible for recording their activity promptly and accurately, with any matters of concern escalated promptly to the registered nurse.

Assistive: Includes registered nursing associates, assistant practitioners and equivalent in all settings.

In addition to the supportive level descriptors, staff at this level have a deeper level of knowledge, skills and training, meeting the standards set for this role by each country in the UK. For nursing associates, this includes the NMC standards. This enables them to carry out a broader range of activities, use their initiative and apply problem-solving skills within their agreed scope of practice, particularly in familiar, low-risk and predictable situations. Where appropriate, they can be delegated to guide the supportive level nursing support workforce, while remaining under the supervision of the registered nurse.

We’ve seen an increase in the number of occasions where positions requiring a registered nurse are being advertised without the essential requirement of a registered nurse qualification.

In England, Band 5 roles for registered nurses have been advertised as open to registered nursing associates.

We take the position that a registered nursing associate should never be used as a substitute because a registered nurse post cannot be filled and has produced guidance to support employers to avoid inappropriate deployment and substitution. Read our position statement for further information.

Substitution of the registered nurse is not safe for patients and not safe for staff. The nursing support workforce must always be deployed in roles where they appropriately, according to their role, support or assist the registered nurse(s).

The nursing support workforce also requires pay, employment terms and working conditions that support safe practice in a safe working environment.

Our Employment Standards for Independent Health and Social Care set out minimum standards that all nursing staff should expect from their employment. Key aspects of these requirements include:

Pay commensurate with the knowledge, skills and responsibilities required to undertake these roles, as well as recognising unsocial working hours and arrangements. The role of a nursing support worker is not recognised as a National Living Wage job. They work at different levels, and their pay should reflect the work that they do and the responsibilities of their role.

Employment terms that recognise the demands of this work and that include enhanced holiday leave, occupational sick pay, maternity pay and flexible working arrangements above the legal minimums.

Working conditions that support the delivery of safe and effective care and ensures they are deployed in roles that support or assist the registered nurse. Access to regular supportive supervision, providing and supporting access to:

• good quality training
• education and personal development
• in addition to mandatory training

Rotas that enable:

• adequate uninterrupted breaks in a suitable environment away from the clinical area
• workplace provision of healthy food and drink facilities
• access to safe changing, shower and toilet facilities

Our Nursing Workforce Standards set out what is required to secure a nursing workforce able to deliver safe, effective, compassionate, person-centred nursing care. Examples are:

• Standard 5 – Each clinical team or service that provides nursing care must have a registered nurse lead.
• Standard 10 – All members of the nursing workforce must be appropriately prepared and work within their scope of practice and (for registrants) in accordance with the NMC Code. A registered nurse must never be substituted with a nursing support worker.
• Standard 12 – The nursing workforce should be treated with dignity and respect and work in environments where equity, diversity, and inclusion are embedded in the workplace culture.
• Standard 14 – Employers must actively protect, promote and support the wellbeing of the nursing workforce.