The RCN's position on registered nurse substitution
Impact of registered nurse substitution on patient care
The RCN has reiterated the risks associated with substituting registered nurses with other roles, with concerns about the impact on patient outcomes.
The evidence we gathered during research in 2023 demonstrates the need to reiterate our position on role substitution for future nursing workforce planning across all health care systems. This comes following our position statement on preserving safety and preventing harm - Valuing the role of the registered nurse (2021), which states the position of the registered nursing associate in England is specifically intended to support the role of the registered nurse and never be used as a substitute for a registered nurse post. As highlighted in the case studies provided below, substitution of registered nurses is becoming increasingly prevalent across different care settings.
The implementation of role substitution and the development of new roles has been a key policy agenda of previous governments in pursuit of the ‘modernisation’ of the NHS. According to leading experts, without clear role definition, workforce substitution will continue undiscussed and unplanned and compromise the quality and safety of care. It has also been linked to a heightened risk of patient death, according to a study published by BMJ Quality and Safety (2016).
What is nurse substitution?
The term substitution (in the context of the nursing workforce) means the deliberate and planned replacement of a registered nurse with either the nursing support workforce or a member of another health profession.
There are various contexts to registered nurse substitution, including the replacement of a registered nurse by the nursing support workforce or other allied health professionals, and the substitution of field-specific registered nurses. Registered nurse substitution is not when there is a planned needs-led skill mix review or when a short-term redeployment occurs to cover short-term gaps.
Role substitution is seen to blur boundaries between registered and unregistered nurses with the potential for role conflict and confusion regarding accountability and safe delegation. Nursing support workers may be considered responsible for a particular task at a specific time, while another time, registered nurses may want to retain the area of work which was previously delegated.
In 2018, we published the following statement in the Staffing for Safe and Effective Care publication, highlighting the registered nurse’s role as critical to the delivery of safe and effective care for patients and clients. This is aligned to the Nursing and Midwifery Council (NMC) Code (2018) highlighting our position for role substitution at that time:
“The RCN supports the development of nursing support staff and recognises the contribution that they make to the care of patients. We do not support role substitution, where registered nurses are substituted with nursing support staff. Evidence supports that to ensure patient safety, registered nurses are required.”
In 2021, we updated our statement as follows: “The RCN is calling on all employers working within health and social care to ensure that where a vacancy exists for a registered nurse, this should be open to registered nurse applicants only. Increasing evidence that this call has not been heard has led to the need to expand on that position in order to focus on the risks to patient safety when the registered nurse is substituted with another health care worker.”
A literature search was conducted in February 2023 for articles published after 2003. A total of 52 papers were found to be relevant, alongside publications from the NMC, National Health Service (NHS) and the RCN. The evidence gathered demonstrated that across all fields of nursing substitution of ‘work’ or ‘roles’ was not a new concept.
Nurses have been moving their work boundaries and working at the top of their practice. Nurses have also been seen to undertake increasing complex medical work, whilst also delegating work considered historically as ‘traditionally’ nursing within an increasingly expanding health care workforce.
The themes evidenced within the literature provided context and evidence that registered nurse work substitution, by either the nursing support workforce or a member of another health profession, has a negative impact on patient care outcomes.
Evidence has highlighted role substitution occurring across all health care settings with registered nurses work being delegated to the nursing and health care support workforce. The number of nursing support workers has increased as roles have increased. As a result, along with other stakeholders, we have called for standardisation and national regulation of the role of a nursing support worker.
Concerns have been raised about a lack of regulation, which places the public, registered nurses and nursing support workers at risk. There is also concern about the lack of a consistent approach to education, scope of practice and the regulation of the role of nursing support workers.
Our publication Impact of Staffing Levels on Safe and Effective Patient Care (2023) highlights the impact of low staffing levels on safe and effective patient care delivery leading to a diluted registered nurse workforce and contributes to preventable deaths.
The review described the impact of staffing levels on safe and effective care delivery, concluding that having correct ratios of nursing support workers is essential to deliver patient safety; however, nursing support workers should not be used to offset a shortfall in the registered nurse workforce.
Nursing associates have been part of the NMC register since 2018 (England only). The role was introduced in response to the Shape of Caring review (2015) to help build the capacity of the nursing workforce and the delivery of high-quality care (HEE) Health Education England.
The nursing associate role was introduced to provide a bridging role between unregistered healthcare assistants and registered nurses, filling a perceived skills gap and offering an alternative route into nursing. Nursing associates are described by the NMC as members of the nursing workforce who have gained a foundation degree, typically involving two years of higher education. They undertake valuable roles in health and care services; however, they are not nurses and it is intended that this role should support registered nurses by enabling them to focus on more complex clinical duties.
Wales and Northern Ireland are in the process of reviewing the role of the nursing support workers prior to considering introducing a regulated, assistive nursing role. In Scotland, a review of nursing support worker roles has been carried out and a new, unregulated assistant practitioner role is being adopted across health boards.
An evaluation of the Nursing Associates role, published by Kings College London (2020), showed that trusts were developing the role and associated competencies to meet the needs of the services provided, adding to the degrees of variation across employers and settings. This has led to the blurring of boundaries and concerns that nursing associates are being recruited into registered nurse vacancies.
The RCN (2021) previously stated that the position of the registered nursing associate in England is specifically intended to support the role of the registered nurse and never be used as a substitute for a registered nurse post. As highlighted within the case studies provided below, this is becoming increasingly prevalent across different care settings.
Within the literature the growing variation of role development within nursing is leading to work allocation substitution across varied health care systems. The workforce strategies deployed to satisfy the gaps have not been effectively implemented to provide safe care.
With the growing nursing and health care support workforce in the UK, there is a need for wider standardisation of the nursing workforce roles and implementation of robust role definitions and scope of practice.
Substitution case examples within current practice
Within a 62-bedded acute medical ward the establishment is for 9 Band 5/6 registered nurses and 3 health care assistants (HCAs) for a day shift. The trust adapted its workforce recruitment strategy due to long standing registered nurse vacancies to encompass recruiting Band 4 nursing associates (NAs) into Band 5 registered nurse vacancies.
The NAs were substituted into rostered Band 5 shift regularly, often giving 6 registered nurses, 3 NAs and 3 HCAs, therefore diluting the registered nurse patient ratio.
RCN NA members have highlighted they are currently caring for level three patients, requiring titration of intravenous medications, ventilation, and hemofiltration care. The NAs describe their roles as working as the registrant accountable for their patients reporting to the unit nurse in charge.
The NAs raised their concerns as they are being employed into registered nurse posts (role substitution).
Substitution of role case example came from a CQC (Care Quality Commission) inspection into an inpatient Mental Health Trust. The unit found difficulty recruiting mental health nurses. As a result, they relied on agency staff to cover nursing gaps. As part of the Trust’s annual strategy, to cut back on agency spending and develop creative means to overcome the ongoing mental health workforce challenges, the workforce plans extended recruitment specifications to allow adult nurses to take vacancy gaps for mental health nurses. Mental health nurses have been substituted with adult registered nurses, who receive a three-month deep-dive programme to support their knowledge and skills within mental health.
The unit rostered one mental health registered nurse always to support the mental health act requirements. On one occasion the unit could only be staffed with adult registered nurses. The trust made the decision a registered nurse to be any registered nurse and that nothing was explicit within the mental health act code of practice to suggest this must be a mental health nurse.
On this occasion an incident occurred when a new patient came into the hospital voluntarily. The patient become increasingly unwell, seemingly lacking capacity, and would need to be assessed for detention under the Mental Health Act. The two adult registered nurses were concerned for the patient’s welfare and sought advice from the crisis team. The crisis team nurse suggested invoking Section 5(4) of the mental health act, restraining the patient, and providing rapid tranquillisation, getting the on-call doctor to undertake an assessment as soon as possible.
The ward team restrained the patient and gave them a rapid tranquillisation. The patient soon calmed down. The nurse in charge of the shift contacted the on-call doctor, who informed them that they would come to the unit in a couple of hours, so they should complete the Section 5(4) papers by then. The nurse in charge printed the documents and filled them out.
A few weeks later, the unit was visited by CQC, which was undertaking an unannounced mental health act review. After scrutinising the mental health act documents, the CQC made a serious complaint to the Trust’s executive team due not following the mental health act regulations.
Examples have been raised by adult nurses to the RCN where nurses are potentially being put in situations where they risk extending their scope of practice beyond their remit within postnatal ward areas. Adult nurses are being employed to provide post operative care, to women following caesarean section; however, they should not be providing postnatal care, as this is the realm of midwifery practice.
The issues raised are when there are staff shortages, nurses may find themselves looking after these women without sufficient midwifery support to provide the postnatal care.
A detailed Healthcare Safety Investigation Branch (2022) investigation into medicine omissions in learning disability secure units, highlighted how learning disability nurses were regularly substituted to fill rota gaps with mental health nurses.
The investigation concluded that the competencies and skills of learning disability nurses and mental health nurses differ greatly when considering how patients are engaged, and specifically when taking medication, this was a key failing of missed appropriate care which led to patient harm.
With ongoing severe staffing issues, many care homes have reduced the number of registered nurses that they have on shift and increased the nursing support workforce. One nurse reported that she was the only nurse on duty for 60-65 residents, whilst another was the only nurse on shift for the whole home over a weekend.
This leads to reliance on the nursing support workers to alert them if a resident is becoming unwell leading to delayed emergency intervention and reduced patient mortality. The registered nurse looking after so many residents, highlights how substitution could not be avoided with the staffing ratios skill mix.
There have been examples spoken of by district and community nursing team members where members are potentially finding they are at recurring risk of dealing with issues outside of their remit or current scope of practice. There is an apparent iterative process of substitution which is progressive and recurring.
There is evidence of community staff on variable grades taking on more roles within the grade without direct supervision, or that may have previously been the remit of the RN only. There may also be some teams managed without SPQ leadership, thus potentially impacting on clarity around supervision and skill mix for those community nurse services.
- Health Education England, HEE (2015): Shape Caring Review.
- NHS (2019): The NHS Long Term Plan.
- NHS England (2017): Delegation of healthcare tasks to personal assistants.
- NMC (2018): The Code: Professional standards of practice and behaviour for nurses, midwives, and nursing associates.
- NMC (2018): Standards of Proficiency for Nursing Associates (PDF).
- NMC (2019): What context factors we think are important to know about when considering a case.
- Nuffield Trust (2017) Reshaping the workforce to deliver the care patients need.
- RCN (2018): Royal College of Nursing response to the Department of Health’s consultation on the Regulation of Nursing Associates in England.
- RCN (2021): RCN position on preserving safety and preventing harm - Valuing the role of the registered nurse.
- RCN (2023): RCN Scotland’s Nursing Workforce in Scotland.
- RCN (2023): Impact of Staffing levels on safe and Effective Patient Care.
- RCN (2023): Raising and Escalating Concerns
- Skills for Health (2021): Our Health Heroes: Meet three incredible Operational Support Workers dedicated to keeping our NHS people, systems & processes running.