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Nursing associates: how employers can make the most of the new role

Workforce decisions need to be made about how nursing associates fit into the wider healthcare team

Workforce decisions need to be made about how nursing associates fit into the wider healthcare team


Picture: iStock

After two years of training, the first-ever nursing associates have now qualified from their programmes and joined their own section of the Nursing and Midwifery Council (NMC) register.

‘I have been waiting for 17 years for a role like this to come along,’ says Cheshire and Wirral Partnership NHS Foundation Trust director of nursing and therapies Avril Devaney.

‘From the start, we have seen this as an opportunity to add to our skill mix,’ she says, explaining why her trust was keen to be one of the first 11 pilot sites set up in 2017.

Creating complementary roles

At a time when the NHS in England is in the grip of a workforce crisis involving 41,000 nurse vacancies, this view is shared by other nursing leaders involved in the pilots.

Leeds Community Healthcare NHS Trust's interim executive director of nursing Stephanie Lawrence says it is ‘exciting’ to be determining how the nursing associate role can both complement nurses and relieve pressure on them.

‘In a short time, they have made a big difference to patients, their families and staff’

Royal Devon and Exeter NHS Foundation Trust chief nurse Em Wilkinson-Brice

The role was created to address a skills gap between band 3 healthcare support workers (HCSWs) and band 5 nurses in England.

Royal Devon and Exeter NHS Foundation Trust chief nurse Em Wilkinson-Brice calls it ‘a dynamic new career pathway’ into nursing.

‘In a short time, they have made a big difference to patients, their families and staff and I am looking forward to welcoming our first wave of qualified nursing associates,’ she says.

Formal career pathway

Many of the early trainees have a background in healthcare and were already working as HCSWs but had no formal career framework through which to progress.

Nursing associate training offers candidates a route to becoming nurses if they choose to continue training; and the government anticipates 40% will do so.

Chief nursing officer for England Ruth May says nursing associates will play ‘an essential role’ for patient care and in supporting the entire nursing profession.

But as the first cohort enters practice, nursing managers may be understandably nervous about the best way to use the new role, especially if they have not been involved in the pilot training scheme.

The development of nursing associates is still an unknown in terms of its likely effects on the nurse workforce and it did not receive the warmest of welcomes in the profession. When it was announced, concerns were raised about it being a cheap way to replace nurses, as well as it threatening nursing’s graduate-entry status.

‘With England facing a clear shortage of registered nurses, it is vital employers do not attempt to fill any gaps with nursing associates’

RCN England director Patricia Marquis

Critics will be watching carefully to ensure nursing associates, who will be paid at Agenda for Change band 4, are not used merely as cheap substitutes for nurses.

Note of caution

RCN England director Patricia Marquis warns: ‘With England facing a clear shortage of registered nurses, it is vital employers do not attempt to fill any gaps with nursing associates.


Patricia Marquis

‘Nursing associates should never be asked to act outside their remit; this risks putting undue pressure on individuals, who must not be made to carry out duties that fall outside their regulated role. This would be unfair and could threaten patient safety.

‘This is a valuable support role designed to work as part of the wider clinical team; however, it is not a replacement for a registered nurse. Nursing associates will deliver and monitor care that has been prescribed and evaluated by a registered nurse,’ she says.


Avril Devaney

In Cheshire, Ms Devaney is aware of continuing concern about substitution.

‘We have been very mindful of that,’ she says. ‘But what we have done is say, “Where do we think nursing associates will be safe and add value to the skill mix?”’

Professional boundaries

Ms Devaney thinks the introduction of the role has helped resolve issues related to some HCSWs doing more than they should, and some nurses acting down.

3 years

Revalidation interval for nursing associates and nurses

‘Nursing associates should help everyone keep to the appropriate limits of their practice,’ she emphasises.

‘We have had feedback from nurses who are saying nursing associates are helping them to work more towards the edge of their practice; that is our hope. We believe nursing associates can manage care for people who have got more predictable outcomes.

‘I don’t see this role as a threat to degree-educated nurses. This will free them up.’

But challenges have included dealing with uncertainty and assumptions about the role.

‘Look at where nursing associates will be safe and where they will add value, talk to people and teams and see how trainee placements have gone’

Cheshire and Wirral Partnership NHS Foundation Trust director of nursing Avril Devaney

Ms Devaney says putting support into and educating teams with trainees where permanent nursing associate posts are being created is essential to ensure existing staff are ready for the role.

But an element of trial and error has informed placements and has required flexibility.

Ms Devaney says two trainees were placed with a home treatment team in the belief they would add value there, until it became apparent their skills did not match what was needed.

‘Look at where they will be safe and where they will add value, talk to people and teams and see how trainee placements have gone.’

Finally, because nursing associates are not divided into fields of practice, they have can be deployed flexibly across a variety of healthcare settings. They are person-centred too, she adds.

Employers’ influence on placements

Ms Lawrence, who also leads practice nursing for the Leeds GP confederation, is keen to reiterate the need to look at where skill gaps exist and what knowledge base is important for individual organisations.

‘The training nursing associates get is robust, and we had quite a lot of control as employers about where they should go on placements,’ she explains, adding that this was important for a complete understanding of patient groups.

Although there are only three stipulated areas of practice, namely hospital, home and close to home, Ms Lawrence says her pilot partnership wanted ‘a more rounded experience’ for trainees. Accordingly, the nursing associates being trained through the West Yorkshire pilot were all given placements looking after children and in mental health.

‘In my experience, we separate physical and mental health but most people with long-term physical health conditions will have mental health issues and vice versa.’

‘The nursing associate role needs national support and leadership to succeed’

NHS Employers chief executive Danny Mortimer

The seven nursing associates Ms Lawrence is taking on have been given roles in their original workplaces, which include a young offenders’ institution and a community neurological rehabilitation unit. They will be monitored over the next 6-12 months.

Like others, Ms Lawrence says her trust will be monitoring the impact of nursing associates on the tasks that nurses have previously had to undertake.

The organisation will assess feedback from staff and patients to judge the effect on patient safety and care.

Guidance for employers

NHS Employers has now published guidance on how organisations can develop and deploy nursing associates, and it includes a one-page guide on the role to be shared with staff.

This guidance offers suggestions about how to establish a training programme, among other things.

Band 4

Nursing associates’ Agenda for Change pay band

It also advises nurse directors how to make a business case for nursing associates, with a checklist of questions, for example on how the new role is likely to affect bank and agency spend and how it can address recruitment and retention challenges.


Danny Mortimer

Chief executive Danny Mortimer says: ‘The nursing associate role needs national support and leadership to succeed.’

Newly published National Quality Board guidelines on nursing associate safe staffing and advice from the Care Quality Commission are all part of new advice for employers.

Only time will judge the success of the new role, but its advocates are clear: with few alternatives, this role is a necessary step into the unknown.

Decisions on deployment

The Care Quality Commission (CQC) has urged providers to adopt a systematic approach to deploying nursing associates.

‘This should involve using evidence-based decision tools and professional judgement,’ explains a CQC briefing.

‘Staffing levels and skill mix need to be constantly reviewed. All providers should adapt and respond to the changing needs and circumstances of people using the service, particularly when introducing nursing associates to a workforce.’

The CQC says it will take enforcement action where it finds problems in relation to regulated activities and breaches of regulations.

Read the CQC briefing

 


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