The role of Nursing Associate (NA) was introduced in England by the government and developed by Health Education England. The NA is a member of the nursing team who is educated and trained to work with people of all ages and across all four fields of nursing: adult, children, mental health, and learning disability.

The role is regulated by the Nursing and Midwifery Council and therefore there are set education and practice standards which must be achieved to become a nursing associate. 

Find out from your trust if you have any nursing associates and go and speak to them about their role. 

To become a nursing associate, you will need to undergo a 2-year apprenticeship programme, during which time you will be employed as a trainee nursing associate. Some universities will also offer this programme as a direct entry programme.

Having some experience in a health care role, such as health care assistant is essential for most employers, although not all.

The Care Certificate is a set of 15 standards that sets out the knowledge, skills and behaviours expected if you are 'new to care'. It is ideal if you have completed this certificate before applying for a trainee nursing associate role. 

The admissions criteria for acceptance onto the Nursing Associate programme includes evidence of level 2 Maths and English skills. Evidence of a GCSE result at grade C (4) for Maths and English would be sufficient. If you do not have this, then you will be asked to sit a numeracy and literacy assessment as part of the recruitment process. Preparing for this assessment is recommended; your employer may provide support to help you with this. Most education providers will request that you then achieve a level 2 literacy and numeracy qualification before you start the programme.

For those coming from overseas, a successfully completed language test such as an International English Language Testing System (IELTS) achieving a minimum overall level of 7 (from 5 December 2018, although, a minimum overall level of 7 is required, a level 6.5 in writing will be accepted alongside a level 7 in reading, listening and speaking), or the Occupational English Test (OET) at level B. 

The Nursing Associate programme is currently an apprenticeship, which means that you will be supported to undertake this by a healthcare employer. The programme is two years in length, which includes work-based learning, placements across different settings and a formal academic programme in an approved education institution.

Some universities will also offer this programme as a direct entry programme.

• Ability to adapt to changing settings and situations
• A strong work ethic
• Compassion
• Attention to detail
• Quick thinking 
• Strong communication skills
• Technology savvy.

While many people wish to continue working in the role, some may wish to progress to be a Registered Nurse. 

Assistant practitioners are a growing part of the health care workforce. Sometimes known as associate practitioners, they take on more responsibilities than healthcare assistants, under the delegation of registered colleagues in a range of different settings.

Assistant practitioners are a highly valued and skilled support role that 'bridges the gap' in many different specialties and may work in a nursing or a therapy role.

All assistant practitioners work within defined local policies and parameters and are accountable for their practice, to their employer, patients and the law.

Taking on opportunities to develop and courses to undertake. For example, NVQ level 3 in Health, NVQ Assessor award; level 3 PTLLS teaching qualification (Preparing to Teach in the Lifelong Learning Sector). Any continuous professional development (CPD) that enhances the role and builds knowledge and understanding.

Speak to other assistant practitioners and to your line manager about development opportunities. Don’t be frightened to ask employers to support further training and education as it benefits the patients.

Maths and English at either GCSE grade C and above or at Level 2 and a minimum of NVQ Level 3 in a health related subject to be accepted on to practice.

Now education and training is through completion of one of the following routes:

• a BTEC Higher National Diploma or Higher Education Diploma, gained through part-time study
• a foundation degree (SCQF Level 8), gained through part-time study delivered by Higher Education Institutions or Further Education Colleges

Assistant practitioners usually follow a therapy or nursing training pathway and undertake a level 5 two-year foundation degree in health or social care, which may be available as an apprenticeship programme.

Assistant practitioners maintain a portfolio, complete competencies, written exams, referenced essays and presentations as part of their education and training.

Empathy, patience, understanding, strength to commit to studying and working fulltime and passion for the role and patient care.

Assistant practitioners may be able to use their previous academic and experiential learning (a process called accreditation of prior experiential learning (APEL)) from any of the above level 5 academic qualifications into the 2nd year of a Registered Nurse BSc programme.

In practice progression can lead to roles in education, governance, research or different clinical areas.

Registered Nurses work as part of a team and provide care for adults and children with physical or mental ill health. The RN can work in a multitude of settings – hospital, general practice, a range of community settings and care homes, to name a few.

The job can vary from helping someone learn basic daily tasks to administering life-saving drugs. Whichever area of nursing you work in, you’ll be assessing, diagnosing, planning and evaluating treatment.

• Speak to local colleges and education providers, schools, universities. Speak to your employer and ask what support they may be able to offer you.
• Read about the differences between doing a full-time nursing degree and completing the degree via an apprenticeship route. Use the health careers course finder to get a list of universities approved to run degree programmes in nursing.
• Have a look at the following information on nursing degree apprenticeships. 

• The traditional route is to take an approved full-time university pre-registration degree in nursing. Additional routes are being developed in England, including nursing degree apprenticeships.
• In England the nursing associate role would enable you to gain experience and then complete the nursing degree apprenticeship over a shorter period.
• Once you have completed the Nursing degree programme or degree apprenticeship, you must register with the Nursing and Midwifery Council before you can practise.

All nursing degrees consist of academic study and practice learning placements relevant to the chosen field. There are four fields of nursing (adult, Child, Mental health and learning disability). If, for example, you choose to go into mental health nursing, the practice learning placements will be mainly be concentrated in that environment and will focus on patients with mental health problems.

However, certain aspects of training will be common to all fields of nursing, and there will often be opportunities to study alongside students on other healthcare courses.

All applicants must be numerate, of good character and health and, above all, be passionate about providing compassionate care to patients. Undergraduate degrees are available on a full-time and part-time basis.

• Able to and enjoy working in teams
• Recognising and acknowledging others views
• Communicating effectively
• Listening
• Networking
• Influencing and persuading
• Personal awareness
• Professionalism
• Confidentiality
• Accountability
• Honesty and trust
• Compassion
• Acting as an ambassador

Nursing is a wonderful career. You can work in any of the pillars of nursing: clinical, education, research and leading and managing.

Registered Nurses work as part of a team and provide care for adults and children with physical or mental ill health. Nurses work in a multitude of settings – hospital, general practice, a range of community settings and care homes, to name a few.

The main role of a Registered Nurse in Mental Health is to build therapeutic relationships with patients/service users, develop care plans with them and support them through a difficult time by empowering them and enabling them to take control over their health.

Follow your passion for your work by undertaking opportunities to take on other aspects of work (for example audits) and take as much initiative as it is possible. You may be fortunate enough to be sponsored by your employer to study via the apprenticeship route.

For the duration of the training as an apprentice you will receive pay and time counting towards continuous service.

There are academic requirements. The ability to analyse complex information, bring together multiple sources, make a coherent argument and develop a plan in collaboration with nurses and other health care professionals and with service users and carers.

There are many important technical and softer communication skills to develop such as assessment and understanding technology; developing the human aspect, listening, empathy and compassion. These are skills that are learnt from behaviour modelled by mentors and peers.

Universities are really good at supporting students in how to study at degree level; there are many resources available to support all students no matter how long ago people undertook formal learning.

Nursing students spend time both in university and in practice, the academic work and learning on placement both bring challenge. You will be supported and learn from mentors and supervisors.

Training doesn’t end on graduation; it is an ongoing part of professional development.

Listening is one of the most important personal characteristics, followed and supported by natural curiosity. There’s a real need for advocacy in mental health as well; nurses need to advocate for those who are vulnerable, in crisis, have complex health and social needs.

Nursing is a wonderful career. You can work in any of the pillars of nursing: clinical, education, research and leading and managing.

The role of the RNLD involves responding to the needs of individuals with learning disabilities, their families and carers with evidence based interventions necessitating creativity, flexibility, and a commitment to promote the empowerment of people with learning disabilities.

While the work of a Learning Disability Nurse can vary greatly depending on the role it is always based on strong values; human rights; equality and inclusion; person centredness; partnership and respect. And of course the 6 Cs; care, compassion, competence, communication, courage, commitment.

By working at 3 levels;

• Specialist individualised interventions to effectively identify and meet health needs;
• Reducing health inequalities through multi-disciplinary working to ensure the implementation of reasonable adjustments
• Engaging strategically to promote improved health outcomes for people with learning disabilities, address inequalities and improve access to general health services.

Have courage, determination, compassion, empathy and joie de vivre!

It keeps on going… qualifying as a Learning Disability Nurse is the beginning of life long education and learning. What a privilege!

Tracey met so many Learning Disability Nurses, all individuals, with different personality traits and characteristics. But they all have in common their strong value base, dedication and passion to work alongside people with learning disabilities to improve outcomes and address inequalities.

Learning disability nurses are found in many positions, with many opportunities available to them. The best is the opportunity to make a real and positive difference to the lives of people with learning disabilities.

As a volunteer on a Trauma/Orthopaedic ward, I was able to work closely alongside the clinical staff. This gave me a fantastic insight into life on the wards and a great deal of admiration of the hard work and commitment I saw on a daily basis. Over time my confidence grew along with my will to be a part of the team. I then set out to accumulate the minimum of 6 months and 50 hours of volunteering that guarantees an interview for bank nurse HCA.

 

After being successful at interview, I started working on many of the different wards to gain more experience and a better understanding of the Trust. I had the pleasure of working on Orthopaedics, Stroke, Frailty, Cardiology and surgical wards. Eventually, I decided to try A&E and instantly bonded with this department. I've honestly never worked as hard in my life, but everyone was so helpful and kind. I knew then this was the place for me, finally after such a long time I felt like I finally belonged, and I had found my place in the NHS. After 6 months I was offered a full-time position and I have now been there nearly 3 years.

During my time on A&E, I have gained my Care Certificate which is now mandatory. I have also been extensively trained in many different areas such as:

• cannulation and venepuncture, equality and diversity
• VBG (variable blood gases), ANTT (aseptic non touch)
• sepsis screening, information governance
• BSL (basic life support), resuscitation quality improvement
• bladder scanning, infection prevention and control.
  
  

Since working for the trust, I have had the privilege of looking after many vulnerable people in their hour of need. Sometimes just a friendly smile, a respectful approach and simply holding their hand can put them at ease. Listening to a patient can expel any anxieties they may have and help them feel valued and cared about. A lot of these characteristics are very basic but go a long way to providing person centred care. Most importantly, the trust's 5 star patient care and values have become the foundation of this award winning trust - that we as health care professionals strive to model ourselves on and ensure we remain the hospital of choice in the North West for many years to come.

You can find out more simply by visiting your local trust website, NHS jobs, or by contacting them directly.

Working within the trust has led me to so many opportunities. The sky is truly the limit if you have the vision, drive, determination and love for the job. Many of the nursing staff and seniors I work with have started their NHS journey as volunteers, cleaners, caterers, porters, receptionists. My journey I feel has only just begun. Recently through the support of my managers I have secured a place to study my Level 3 Senior Healthcare Support Worker. On completion I will be able to apply to study Adult Nursing. After that I wish to re-join my A&E family in blue scrubs, rather than grey. The rest, who knows?

The role varies depending on who employs them but here are a few things a care navigator does to make the difference in the experience of care that patients received:

• Explaining and demystifying the jargon to patients
• Making sure that care and support is appropriate
• Personalised advice can save time and anxiety
• Ensuring the right care is being accessed. This includes for someone who is due to be discharged from hospital or living at home and just needs a little support and advice.
• Help to plan ahead and use help to stay as independent as possible.  Not wanting or needing care just now but would like to know what services there are available to help you stay at home and independent for as long as possible.
• Following the loss of a love one. It can come as a shock to family following a bereavement just how much the person who has passed was doing for their partner or spouse and it is clear that some help needs to be put into place.

There are many ways you can get experience of working within a particular team focusing and the best way would be to talk to the Clinical Nurse Specialist (CNS) teams and shadow them in their role for valuable work experience.   Find out if there is a Care Navigator in post and speak to them about their role and arrange time to shadow them.  Care Navigators are a really friendly bunch who are only too willing to share their knowledge and experience.

Gain an understanding of the role of the CNS as Care Navigators work very closely with them and it is useful to know how you to best support them.  Identify any transferable skills you can bring to the role. Take a look at the Macmillan websites which has some valuable information on different cancer types.

 

Seek courses or modules that cover the essential knowledge and skills to work as a Care Navigator such as The Association of Medical Secretaries, Practice Managers, Administrators and Receptionists (AMSPAR) Introduction to Medical Terminology and/or Health Service Administration. Once in post, Macmillan offer some excellent courses such as Advanced Communication courses and the Recovery Package and Motivational Interviewing.

• The Care Certificate
• RCN Introduction to leadership programme
• GCSE A-C grade in English or equivalent
• RSA III is helpful as is The Association of Medical Secretaries, Practice Managers, Administrators and Receptionists (AMSPAR) or equivalent secretarial experience and European Computer Driving License (ECDL) or proven equivalent experience in Microsoft Office (MS) Package, email and internet browsers

• Excellent written and verbal communication skills combined with an effective and courteous telephone manner
• Able to demonstrate tact and diplomacy
• Ability to contribute to team and be a part of the multi-disciplinary team (MDT)
• Ability to deal with people who are distressed but work within own scope of practice.
• Able to negotiate with other teams to ensure an effective journey for patients throughout the organisation.
• Analytical skills & problem solving skills.
• Ability to work under pressure and exercise judgement when dealing with inquiries.
• Flexible and adaptable to the changing needs of the service.
• Ability to work without supervision and use own initiative.
• Ability to concentrate even with frequent interruptions and unpredictable working pattern
• Effective in managing own time
• Ability to prioritise; to be organised and flexible.
• Able to effectively accommodate adhoc demands to existing workload
• Neat, tidy and able to portray a professional image

A nursing career or possibly operational management or an education role.

HCSW’s (Health Care Support Workers)  are the biggest part of the workforce within the Community Children’s Nursing Team and take on a lot of responsibility that is directed by the Registered Nurses and management. On occasions the more senior HCSW’s take on the role of delegation to junior staff and also student nurses.

All HCSW's work under the Code of Conduct for Healthcare Support Workers and are accountable for their actions. Within this specialist area they may provide enteral feeding, daily medication to named children, suctioning, oxygen therapy, tracheostomy care, non-invasive positive pressure ventilation, recognising and monitoring the signs of seizures, changing ileostomy bags, venepuncture, Electrocardiogram’s (E.C.G’s) along with the daily monitoring of the children’s health.

HCSW’s in this specialised area are also responsible for multiagency working with other health professionals and the staff in the schools to ensure high standard of care and that everyone is kept informed of changes.  

Completing the NVQ level 3 in health and social care or childcare.

Previous experience in healthcare.

Taking on any courses and opportunities to develop knowledge and understanding of the job.

Gaining experience of working with children. 

Seek opportunities to work with children and young people and if possible, those with additional needs. Speak with other HCSW’s who may work within a continuing healthcare environment to see what experience may be needed. If not able to, then other HCSW’s or registered nurses who work within health and care will be able to give you some information or answer questions.

Reading up on the role is very important and researching different diagnosis and health conditions. Speak to colleges to see what courses they have and to see if they would be beneficial to the job role.

Maths and English at GCSE C and above and NVQ level 3 in health and social care or childcare.

In Wales, there may be the opportunity to complete the Certificate of Higher Education in Health Care Nursing Support Worker. 

All other training is then done within the job. HCSW’s have their individual training records with mandatory and statutory training needed on an annual basis and is their responsibility to maintain this. HCSW’s in this specialised area have annual training for Enteral feeding, medication, suctioning, oxygen, tracheostomy and non-invasive positive pressure ventilation. Following this a registered nurse  must sign them off as competent to undertake these skills in practice. 

Patient, empathetic, understanding, sympathetic, team worker but also have the ability to work on your own, good communications skills, ability to adapt in situations, passion for the job and to provide the highest standard of acre to the children and their parents, good record keeping.

Can use the caring experience to do the Certificate of Higher Education in Health Care Nursing Support Worker Education. It can lead to the BSc (Hons) Nursing degree.

The experience from this role can be transferred to adult continuing healthcare or onto the adult wards and the Assistant Practitioner (AP) role.

What is an Associate Practitioner

An Associate Practitioner, also known as an Assistant Practitioner, is a role with more responsibility than that of a health care assistant or support worker, but also has work often delegated and overseen by a registered nurse or other registered practitioner.

Associate practitioners work within defined local policies and parameters and are accountable for their practice, to their employer, their patients and the law.

Kevin’s role involves working with the community nursing team and the community specialist nurse practitioners (CSNP) within the community and nursing homes. He provides care to people where they live, including supporting them to wash and dress, doing wound dressings and helping them to manage their diabetes. He also liaises with hospital teams to support the prevention of hospital admissions wherever possible.

How do you make this change

Kevin knew that he would have to undertake additional education and training to achieve his goal to become an Associate Practitioner. He successfully completed NVQ level 2 and 3 in health and social care. Kevin is always keen to undertake courses offered by his employer over and above the mandatory training.

Kevin undertook the RCN First Steps programme which he found to be a very useful grounding to the further education that he undertook

To become an Associate Practitioner Kevin undertook a foundation degree at a higher education institution which took 2 years to complete.

What do you need to do to become an Associate Practitioner

Kevin spent time talking to colleagues already in the role and his managers about his prospects of moving into this particular role within the organisation. He spoke to the education team about the education he would need to help him to achieve this role. He researched the role on the Health Careers website and also spoke to human resources in his organisation.

By doing this, he learned what opportunities were available to him and what additional education he would need to compliment his experience and meet the essential criteria for a future position.

From there, he was able to make a plan and set goals to achieve his ambition.

What does leadership mean to you?

As an Associate Practitioner, Kevin leads the delivery of care for some of his patients. He has the knowledge, experience and confidence to mentor new and junior staff, supporting and guiding them in their roles. Kevin has grown in confidence and feels able to share ideas with the whole team, and to put them into practice within the scope of his role.

Education and training

Maths and English at either GCSE grade C/4 and above and a minimum of NVQ Level 3 in a health related subject to be accepted on to practice.

There are 2 education routes to becoming an Associate Practitioner:

• a foundation degree (SCQF Level 8), delivered by higher education institutions or further education colleges
• a foundation degree apprenticeship (in England), gained by working and learning at the same time.

Trainee Associate Practitioners maintain a portfolio, complete competencies, written exams, academic essays and give presentations as part of their education and training.

Personal characteristics

Kevin prides himself on being professional at all times and a bit of a perfectionist. He likes meeting and engaging with lots of different people and considers himself to be a real team player. He also loves to sing and have a laugh with his patients. He finds this to be beneficial to those he works with.

Where the role can lead

Associate Practitioners can undertake further study to become a Registered Nurse. Using their previous academic and experiential learning (a process called accreditation of prior experiential learning (APEL)) from any of the above level 5 academic qualifications to undertake a shortened Registered Nurse Degree Apprenticeship.

Associate Practitioners can work roles related to education, governance, research or different clinical areas.

The main responsibilities for an AP or NSW in a teaching role is to ensure that Health Care Support Workers achieve outstanding progress throughout the course. This is accomplished by careful planning, teaching and class management. They will be involved in the designing and delivering of teaching materials and use of appropriate teaching and assessment methods. They are also responsible for making sure that teaching plans are regularly reviewed and refreshed.

The teaching consists of independent learning and taught workshop sessions that are devised to challenge thinking, foster debate and develop the ability of students to engage in critical discussion and rationale thinking and of course, to be fun!

Teachers need to be aware of and make provision for Health Care Support Workers who have different learning styles and needs. All students need support as and when needed via face to face meeting, telephone or emails. Throughout the course students will undertake workplace activities and competencies which need to be signed off by their workplace mentor. They will liaise with the mentors to ensure understanding of their responsibilities.

Teachers contribute to setting assignments, marking all activities and ensuring all students are given feedback every step of the way. Once the portfolios have been completed, they will check that the student has achieved the learning outcomes, aims and objectives of the course and award before the portfolios are submitted for internal and external verification. During this period, teachers will liaise with examination bodies to arrange inspection dates, and once the students have their achievement confirmed by the awarding body it is their responsibility to ensure the certificates are sent to the students.

To move into this role, you could make contact with the local Human Resources (HR) department or your line manager to express an interest. If you do not currently have a teaching post in your setting, then identify where there is a training need that you feel would be an appropriate topic for you to teach. Don’t be afraid to put yourself forward.  Most people interested in teaching and learning come upon this role by chance.

Speak to registered nurse colleagues who lead, for example the Practice Nurse Advisor as they will need the support of an AP or HCSW advisor. Find opportunities to contribute and look for the support and encouragement from colleagues.

You will need a passion for teaching!   

To become an AP teacher, you will need the capability to work independently, be able to multitask and to work under pressure. You will have to prioritise and meet deadlines. You will need the ability to learn quickly and adapt to new structures and procedures.  Passion for innovation and continuous improvement with a willingness to embrace change is essential.

Your ability to develop practical solutions to problems and a commitment to take a hands-on approach is vital. You should be able to demonstrate assertiveness resilience, accountability. and have a good knowledge of tutors’ professional duties and legal responsibilities.

For this level of practice, you will certainly need one of the following:

• a BTEC Higher National Diploma or Higher Education Diploma
• a foundation degree (SCQF Level 8)   

It is also useful to have or be prepared to undertake one of the following:

• a nationally recognised award in education and training
• NVQ level 3 Assessor award
• Level 3 Award in Education and Training

Several organisations you may do some teaching for run Train the Trainer courses that help to familiarise you with the programme you will be delivering. It is very important to understand the fundamentals of training and develop knowledge of the key concepts in practical training. Successfully completing one of these qualifications will provide a fundamental understanding of the roles and responsibilities of a teacher/trainer in relation to legislation, equality, diversity, inclusivity and meeting the needs of learners.

Also being able to structure learning, plan and deliver sessions, using appropriate resources and teaching methods. You should also be able to identify the characteristics of effective assessment and feedback. 

You will need some essential personal skills to become an AP or NSW teacher/trainer. You must have a passion for learning and teaching and strive for high quality safe and effective patient care.  You should be enthusiastic about the course you are teaching and encourage students to share the same passion.

Leadership is important. A good teacher leads by example and has the ability to lead and guide the students and manage a number of personalities as well as being sensitive to different points of views.

You will need exceptional organisational skills and must have remarkable communication abilities and a good sense of humour too!

Start by researching what happens with HCA teaching provision in your setting. Contact your HR department and ask about possible opportunities and express an interest that you would like to develop your career as a teacher. Ask other teachers for their help and advice and see if they can signpost you in the right direction. Be prepared-find out where you can access a train the trainer course.

Further develop your teaching role by undertaking a level 4 award in the Internal Quality Assurance of Assessment Processes and Practice.

This award provides the knowledge and skills to effectively quality assure vocational based qualifications. It means that as the teaching team grows, the principles and practices of internal quality assurance techniques and criteria for the monitoring the quality of assessment of other teachers in our team are enhanced.

A research practitioner is a highly skilled individual who works in clinical research delivery in a patient facing setting. This individual will undertake a number of roles to facilitate clinical research including but not limited to recruitment of study participants, patient observations, venepuncture, data capture as well as liaising with external stakeholders to deliver clinical research both safely and effectively.

Currently, it is an unregistered role however, the National Institute of Health Research and Academy for Healthcare Science are collaborating for clinical research practitioners to be a professionally accredited role.

Email the local research team at your local NHS trust and ask for an insight day. Speak with your line manager and ask for support to do this. Speak to research staff who come into the ward  area. Don’t be afraid to ask questions.

Experience:

• Camille worked as a Health Care Assistant for ten months in a colorectal ward in Nottingham University Hospitals to get an insight in working in the NHS.
• He is currently a Research Practitioner in Oncology. He has been in the role for 2 years.
• Camille is a member of the Research Practitioners forum/network in Nottingham, working in collaboration with National Institute for Health Research looking to get an accredited qualification for research practitioners. This involves meeting every other month, mapping skills and competencies to be standardised.

• Good level of education is required although diploma/degree isn’t always necessary.
• Most of the training is done on the job, such as good clinical practice and informed consent.
• It does help if you have some basic laboratory experience although training be done on the job for this.

The following once in role:

• Informed consent training
• Good clinical practice training (1 day training – online/classroom, run by National Institute for Health Research (NIHR), updated every 2 years)
• Future Learn Course (online) on Improving Health Care through Research
• Multi-professional education meetings in oncology – learning about different treatments, clinical updates
• Developing skills in leadership and project management through the Research Practitioner Forum/Network

• Friendly, confident and approachable.
• In-depth understanding of the research processes (through higher education and experience)
• Good communication skills
• A range of clinical skills (vital signs, venepuncture & cannulation – can be learned on the job, ECGs – can be learned on the job, depending on the need of service)
• Keeping in touch with others in the same role. This can involve meetings every other month, mapping skills and competencies to be standardised.
• You need to have good organisation and time management skills as you will be expected to manage your own workload.
• You need to be good with computers as you will be have to use a number of different computer systems.

This role can lead to higher level posts within clinical research. As the accredited registration comes into force, hopefully this will lead to better standardisation and clearer routes for progression.