Matter for discussion, submitted by the RCN North Yorkshire Branch
That this meeting of Congress discusses the introduction of the nursing associate role in healthcare.
Following the Shape of Caring review, the nursing associate (NA) role was introduced in England in September last year. Since then, 2,000 trainee nursing associates (TNAs) have started their courses, with TNAs now employed in all NHS trusts in England.
The RCN had not been invited to engage with the work until the Health Education England (HEE) Implementation Group was established in September. Although critical of the lack of involvement at an earlier stage, the RCN has since been able to work with HEE and employers to develop this new role - one which will inevitably become a crucial part of the nursing team in the new integrated health and social care environment. The College has also welcomed the NMC’s decision to regulate the NA role, as it has campaigned for the regulation of health care support workers to increase protection for people receiving care and to ensure that standards are consistent.
The continuing funding crisis in the NHS has led to concerns around the role being introduced as a cost-cutting measure. Janet Davies said, “The nursing associate role is an opportunity to provide support to nurses and improve care. But it’s vital that despite the financial pressures, NHS trusts do not replace registered nurses with nursing associates to save on costs.”
The NA course lasts for two years, with participants employed as Band 3 TNAs. TNAs will attend a part time university or further education college course, which will follow the national curriculum framework as published by HEE in October 2016. On successful completion, they will be entitled to apply for a Band 4 NA position. Pressure from the RCN and Unison has prevented employers employing TNAs inconsistently and at a lower banding, with the Band 3 role having been evaluated through the NHS job evaluation process. The job description for the full NA role has not been evaluated yet, pending the development and agreement of NMC standards for the role.
The NA role provides a career pathway for health care assistants and the NMC regulation and the pan-England approach should promote consistency of title, standards, competence and assessment. However, given the staff shortages there are concerns about the support for practice based learning, including the capacity of mentors or supervisors and of substitution for graduate registered nurses.
The impact of the role and the subsequent changing skill mix of the nursing team on patient outcomes are still to be ascertained. The evidence that good patient outcomes are achieved by having more registered nurses involved in care is strong. Research showed that substituting one unregistered nurse for a registered nurse increases mortality by 21%. For every one patient added to a nurse’s workload there is an associated 7% increase in deaths after common surgery. Every 10% increase in degree educated nurses is associated with a 7% reduction in mortality. Latest research suggests that just one additional trained nurse per 10 beds could reduce the chance of death after 30 days by up to 28%. Evaluation will be undertaken to include patient outcomes.
A number of areas of contention have arisen, particularly regarding administration of medicines and the level of autonomy or supervision required to assess, plan, deliver and evaluate care. These will be explored by the NMC and others as the standards are developed.
The RCN has already begun to recruit TNAs into RCN membership. It is crucial that as members of the nursing team TNAs and NAs are welcomed and supported by the RCN.
The RCN will continue to be actively involved in national and regional implementation group work, supporting and challenging plans as appropriate and scrutinising the evaluation of the roles.
There are no current plans to introduce the NA role in Northern Ireland, Scotland or Wales. An NHS Wales skills and career framework is in place to inform the skills and career development of the HCSW workforce, and the Code of Conduct of HCSW in Wales (2011) supports the framework along with other all-Wales guidelines, for example those on delegation. Furthermore, the student bursary has been secured in Wales until 2018. A development framework for HCSW’s has also been developed in Scotland.
Student nurse and first time speaker at Congress, Russell Stringer North Yorkshire Branch asked Congress to discuss if the introduction of the new nursing associate role should be resisted by the nursing profession.
South East Region member Soline Jerram agreed that with a workforce in crisis we need to attract more people to the health care workforce, but these roles require mentorship and supervision from registered nurses and that needs appropriate funding, and a “robust infrastructure”.
Also highlighting that there is a “lack of clear pathways and regulation” Lindsay Cardwell, Health Practitioner Committee said that many assistant practitioners feel “demoralised and side-lined by the new nursing associate role”.
Stressing that the nursing associate role should not be used as a “cost cutting exercise”, Anne Wells, Hertfordshire Branch, said that the role is an opportunity to provide support to registered nurses and improve patient care.
Philip McCaffrey was concerned for the protection of the first level registered nurse in patient care, as there could be a temptation in the future to reduce their numbers and replace with more nursing associates.
Jane George Assistant Practitioner, Lancashire East Branch Manchester was concerned the NMC regulation would not be in place within two years and asked why the money wasn’t going into the assistant practitioner role that is already in place.
June Clark, Glamorgan branch agreed with Celine Jerron that we need to “bring together the plethora to titles, jobs and roles that exist below the level of registered nurse”.
Speaking about the opportunity of this role to “counteract some of the prejudice against working class entrants into the nursing profession” first year student Andrew Smith, Leeds Branch, said the RCN could positively influence this by being involved with the development of the role.
Russell summed up the discussion by saying that we need clarification of where the role is going to work best, if it is going to work and how it will work within the current workforce.