Exclusive: The false job titles that are undermining trust in nurses

Thousands of unregistered NHS support staff have the word ‘nurse’ in their job titles, misleading patients and raising safety concerns, a Nursing Standard investigation reveals

• Patients are being misled into thinking unqualified staff are registered nurses
• Employers suspected of using substitute titles to cover staff shortages and save money
• NHS Improvement urges trusts to conduct reviews and use appropriate job titles

Many NHS trusts in England are using misleading job titles for staff, which nursing experts warn is a risk to patient safety.

Thousands of unregistered support staff in Agenda for Change (AfC) pay bands 1-4 have job titles containing the word ‘nurse’, a Nursing Standard investigation reveals.

The investigation, covering 143 NHS acute, mental health and community trusts, found that 93% had unregistered support staff in post with titles containing the word ‘nurse’.

Nursing and Midwifery Council chief executive Jackie Smith says: ‘If someone delivering patient care has nurse in their job title and they are not on our register, then from a patient’s perspective that is quite worrying.

‘Only a registered nurse should have the word “nurse” in their job title’

‘Employers should not mislead patients into thinking the person in front of them is a registered nurse when they are not. They have a duty to make that clear to patients.’

The investigation backs up a study by London South Bank University chair of healthcare and workforce modelling Alison Leary that was published last September.

Professor Leary found instances of unregistered support workers in the NHS with job titles that described them as nurses with advanced skills.

This prompted NHS Improvement executive nursing director Ruth May and England’s chief nursing officer Jane Cummings to write to trusts to urge them to use the word ‘nurse’ correctly - only when someone is a registered nurse.

Earlier this month, Professor Cummings stepped by this action by announcing she would be looking working with other CNOs to review options for a legal change to protect the title of "nurse" for registered nurses.

Examples of questionable titles

Last November, additional guidance on advanced clinical practice from Health Education England (HEE) also urged trusts to review titles containing the word ‘advanced’ to ensure they meet new standards.

Our investigation found that nearly a quarter of trusts (24%) had staff in bands 1-4 with the word advanced in their job title – one trust had 119 band 3 staff who were called advanced healthcare assistants.

Fewer than one in five trusts (17%) said they planned to review job titles containing the word ‘advanced’.

In total, data revealed that 9,074 staff in these lower pay bands had job titles containing the word nurse, even though a registered nurse must be on band 5 or above.

Not every trust specified the exact job titles these figures cover, and some included recognised titles, such as ‘dental nurse’ and ‘nursery nurse’.

‘Employers should not mislead patients into thinking the person in front of them is a registered nurse when they are not’

Jackie Smith, Nursing and Midwifery Council chief executive  

Examples of questionable titles included: associate nurse tissue viability service (band 4), colorectal specialist nurse (band 2), bank nurse (band 2-3), enhanced supervision nursing assistant (band 2), patient activity nurse (band 3), endoscopy nurse (band 3), pre-registration nurse (band 3), overseas staff nurse (band 3), staff nurse (band 2), escort nurse (band 2), school auxiliary nurse (band 4), candidate nurse (band 3).

When questioned, many trusts said they would review job titles.

Sussex Partnership NHS Foundation Trust uses the job title ‘assistant community psychiatric nurse’ for a band 3 post. A spokesperson said: ‘We acknowledge the points raised here and appreciate that job titles can sometimes be confusing.’

Staff at the trust are encouraged to introduce themselves and explain their role when they meet patients, the spokesperson added.

East London NHS Foundation Trust, which has 54 band 4 ‘nurses’ in post, says it is reviewing all its nursing job descriptions from bands 3-8a. Director of nursing Claire McKenna says the trust will look at the use of ‘nurse’ in titles for non-registered staff. She said it will prioritise band 4 roles identified by Nursing Standard for early review.

Pennine Care NHS Foundation Trust has 577 staff in post using job titles containing the word ‘nurse’, including 501 ‘bank nurses’, mainly at band 2. Interim executive director of nursing and healthcare professionals Jackie Stewart says: ‘We will be undertaking a review of the recent HEE guidance and NHS England recommendations to determine any necessary changes to job titles across the trust.

‘Patient safety is our top priority, so regardless of job title I can provide absolute assurance that our staff will only ever undertake duties that are appropriate to their role and banding.’

‘These names are misleading’

University Hospitals Coventry and Warwickshire NHS Trust has 75 band 2-4 staff with job titles such as assistant practitioner nurse, nurse, newly qualified nurse and pre-registration nurse, though the trust says all its registered nurses are band 5 or above. A spokesperson said some band 2-4 staff with ‘nurse’ in their title are newly qualified or experienced overseas nurses who are at the preregistration stage.

‘As they are not yet registered in the UK, they do not conduct the full clinical duties that a registered nurse is qualified to do.’

‘A bigger, fundamental issue is whether employers are also substituting registered nurses with unregistered support workers because of a shortage of nurses or for financial reasons’

Wendy Preston, RCN head of nursing practice

A spokesperson for the Royal Wolverhampton NHS Trust said it has a small number of staff who have ‘nurse’ in their job title but who are not carrying out a registered nurse role. The trust said it has reviewed its electronic staff records on roles with the title of nurse.

Professor Leary says Nursing Standard’s investigation shows her own research was not a fluke. ‘These results are not great for the public’s understanding of nursing, but at least it has confirmed what we found last year. If these are not registered nurses, then these names are misleading.’

‘This is a huge area of risk that is not being managed’

Professor Leary says she has received about 200 emails from support workers, registered nurses, patients and the public since her own research was published.

‘Some of the stories were horrific, with concerned patients receiving erroneous “advice” from people assumed to be appropriately qualified healthcare professionals but who were in fact members of the public with apparently no qualifications whatsoever.

‘I heard from support workers who felt they were being forced by managers to mislead the public as to their level of qualification and experience.’

She says advanced practice should be regulated to protect the public, given that some employers are using job titles inappropriately.

‘This is a huge area of risk that is not being managed – I really wish there was some legal recourse if a patient was harmed.’

RCN head of nursing practice Wendy Preston says the findings are worrying and many titles ‘do not have much justification’.

‘Having “nurse” in the description gives the impression they are a type of nurse, and it’s absolutely not acceptable – these are assistant posts, and it makes it extremely confusing for the public.

‘This research backs up the call for roles to be reviewed, to have fewer role titles and more clarity’

Wendy Preston, RCN head of nursing practice

‘Overseas nurses are not staff nurses – they are doing work as healthcare support workers, but calling them nurses is like saying they are qualified and registered, in which case they wouldn't be in a band 3 post.

‘We want public confidence in nurses to stay high. This research backs up the call for roles to be reviewed, to have fewer role titles and more clarity.’

‘Some employers aren’t addressing the issue’

Ms Preston says that with definitions of advanced level practitioner clearly given in HEE's advanced practice framework, the RCN's new credentialling programme and the apprenticeship model, it is frustrating that some employers are not yet taking steps to get advanced titles right.

She also worries the data may be evidence of substitution. ‘A bigger, fundamental issue is whether employers are also substituting registered nurses with unregistered support workers because of a shortage of nurses or for financial reasons.’

A spokesperson for NHS Improvement and NHS England says: ‘Providing patients with clarity around who is caring for them should be a priority for all trusts, and this includes using the appropriate job titles for all their staff.

‘Although the word nurse isn’t protected, when it is used patients often expect the person in the role to be a registered nurse. We urge all trusts to review the job titles they use to avoid misleading the public.’

Healthcare assistant promised biopsy to patient

One case in which an unregistered NHS staff member gave incorrect and inappropriate medical advice was highlighted by retired nurse Vanessa Martin, who took a friend with suspected cancer to a hospital appointment.

The consultant told Ms Martin's friend he would like to do a biopsy of the suspicious area, but because of its position he would be unable to do so.

However, a member of staff who was present during the consultation – and who Ms Martin and her friend assumed was a registered nurse – then took them through to another room to take a blood sample.

‘She began to say how wonderful the surgeon was and that he would do the biopsy because part of the protocol of cancer care was to make a diagnosis and to reassure the patient,’ Ms Martin says.

‘I challenged her but she would not climb down, saying that it was important for a patient to have cancer diagnosed quickly. I then asked her if she was a registered nurse and she admitted she was a healthcare assistant. Her badge was not easy to see or read, and her uniform was not clear – another problem.’

Ms Martin complained afterwards and received a call from a senior nurse manager who said she was ‘appalled’ and that the staff member had been reprimanded and sent for further training.