Matter for discussion: Registered nurse substitution

The 2024 RCN’s position statement on registered nurse substitution makes it clear that the substitution of registered nurses with the nursing support workforce or other allied health professionals is becoming increasingly prevalent. Substitution can occur by replacing a registered nurse or field-specific registered nurse. The development of new roles has been a key policy agenda of governments in pursuit of the modernisation of the NHS. February 2024 saw the Welsh government publish The Future of the Band 4 Nursing Workforce in Wales which considers whether a band 4 Nursing role is desirable, appropriate and adds value. However, safeguards are required to ensure the delivery of safe, effective, evidence-based, compassionate care to patients in all health and social care settings. 

In 2016, when the role of the nursing associate (NA) was first being developed by Health Education England with the then Chief Nursing Officer of England, the role of a nursing associate was not to replace the role of the registered nurse (RN). The Nursing and Midwifery Council (2023) states that the “NA role contributes to the core work of nursing, freeing up RNs to focus on more complex clinical care”. Despite the assurances at the time, we are beginning to observe increasing examples of where NAs are replacing RNs in establishments thereby reducing the skill mix. The concern about substitution is that an NA is at risk of practicing outside their scope, with inadequate support and supervision, inappropriate delegation, and risk of exploitation in terms pay and working conditions.

Some nursing roles including leadership roles are being advertised as roles that no longer require an NMC registrant. Hence, allied health professionals can now take them up. The concern about substitution is that RNs working in those environments no longer have direct access to RN leadership. This may impact on them being able to revalidate and engage in professional reflective practice as part of their NMC requirement to practice safety and effectively. 
Substitution of field-specific register nurses is also a concern and has been observed in learning disability, mental health, midwifery, and community services. The vast knowledge, skills, and expertise that RNs in their fields of nursing bring to their work is so important and is evident in the quality of care and care experience patients/people receive. A holistic, person-centred, high quality and compassionate care.

Without action, clear role definitions and legal protections, workforce substitution will continue undiscussed and unplanned which compromises care safety and quality. Although the RCN position statement calls on employers to protect against role substitution, more safeguards are required in these challenging times of cost pressures and workforce availability. This is an ideal opportunity to discuss what safeguards are required and what is needed to protect patients/people and the nursing profession.

References

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Health Education England (2015) The Shape of Caring Review. Available at: https://www.hee.nhs.uk/our-work/shape-caring-review 
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NHS (2019) The NHS Long Term Plan. Available at: https://www.england.nhs.uk/wp-content/uploads/2022/07/nhs-long-term-plan-version-1.2.pdf  

NHS England (2023) Personal health budgets: delegation of healthcare tasks to personal assistants. Available at: https://www.england.nhs.uk/publication/delegation-of-healthcare-tasks-to-personal-assistants/

Nursing and Midwifery Council (2018) Standards of proficiency for nursing associates. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/standards-of-proficiency/nursing-associates/nursing-associates-proficiency-standards.pdf 

Nursing and Midwifery Council (2018) The Code: professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at: https://www.nmc.org.uk/standards/code/ 

Nursing and Midwifery Council (2023) We regulate nursing associates. Available at: https://www.nmc.org.uk/about-us/our-role/who-we-regulate/nursing-associates 

Royal College of Nursing (2018) Consultation response: Regulation of Nursing Associates in England. Available at: https://www.rcn.org.uk/About-us/Our-Influencing-work/Policy-briefings/conr-4217

Royal College of Nursing (2021) Nursing Workforce Standards. Supporting a Safe and Effective Workforce. Available at: https://www.rcn.org.uk/Professional-Development/publications/rcn-workforce-standards-uk-pub-009681

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Royal College of Nursing (2023) Potentially unlawful substitution of mental health and learning disabilities nurses in UK in-patient services – the realities on the ground. Available at: https://www.rcn.org.uk/news-and-events/Blogs/unlawful-substitution-of-mh-and-ld-nurses-in-uk-inpatient-services-021023

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Royal College of Nursing (2024) The RCN position on registered nurse substitution: impact of registered nurse substitution on patient care. Available at: https://www.rcn.org.uk/Professional-Development/Registered-nurse-substitution

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Welsh Government (2024) The future of the Band 4 nursing workforce in Wales: Summary report. Available at: https://www.gov.wales/sites/default/files/publications/2024-03/the-future-of-the-band-4-nursing-workforce-in-wales-summary-report-2024.pdf

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